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Full text of "Harvard medical alumni bulletin"

SPRING 2000 




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ALUMNI BULLETIN 



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Detectives 

urder, Mayhem 
and Microbes 




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LANDMARK 

1889 

The first operation 
to take place in the 
Bradlee Ward of 
Massachusetts Gen- 
eral Hospital. This 
aseptic ward had 
been built the previ- 
ous year to accom- 
modate abdominal 
and brain surgery. 






SPRING 2000 • VOLUME 73, NUMBER 4 



CONTENTS 




DEPARTMENTS 



Letters 3 

Pulse 8 

Faculty spoofs from the second year 
show; a new look at the importance of 
biodiversity; HMS maintains a tradition 

President's Report 10 

by Sharon B. Murphy 

Bookshelf 11 

Benchmarks 12 

Evidence points to a genetic expansion 
behind vertebrate fingers and toes. 
by Misia Landau 

Class Notes 58 

InMemoriam 62 

George Starkey 

Obituaries 63 

Endnotes 64 

Who taught Sherlock Holmes to detect 
clues as subtle as a calloused thumb? 
by Paula Byron 




MEDICAL DETECTIVES: MURDER, MAYHEM, AND MICROBES 



A Single Strand 14 

Forensic detectives are bringing new scientific tools into the 
courtroom to unlock decades old secrets. 

by PHYLLIS L . FAGEU 

Body of Evidence 24 

A physician applies his knowledge of the dead to help the living. 

by BEVERLY BALLARO 

Microbe Hunter 28 

In chasing outbreaks around the globe, an epidemiologist 
encounters the sublime and the surreal. 

by BEVERLY BALLARO 

Dead Men Do Tell Tales 32 

Deciphering the encryptions of the dead requires knowing 
how to read a body. 

by BEVERLY BALLARO 

The Tell-Tale Heart 36 

An infectious disease expert investigates how human attitudes 
and behaviors can promote — or imperil — a healthy society. 

h\ BEVERLY BALLARO 

Murder Most Harvard 40 

A brutal slaying at Harvard Medical School led to one of the world's 
first applications of forensic evidence in court 

by ANTHONY S. PATTON 



FEATURES 



Babies in Saddlebags 

A surgeon recounts his adventures 
working alongside nurse -midwives in 
one of the poorest and least accessible 
areas of the United States. 

by FRANK J. LEPREAU, JR. 

Special Deliveries 




The challenge of ensuring a healthy 
beginning for babies is heightened in 
the resource-deprived Balkans. 

by CHRISTINA ANDERSON 



Cover photograph: John Brooks '94, an Epidemic Intelligence Service officer at the Centers for 
Disease Control and Prevention, tracks outbreaks around the world. Photograph by Lynne Siler. 



Har va rd M edical 



ALUMNI BULLETIN 




In this Issue 

I IS NOW 150 YEARS SINCE PROFESSOR JOHN WEBSTER WAS SENTENCED 

to hang for the murder of Dr. George Parkman, whose body parts 
were once stowed here and there around Harvard Medical 
School. In this issue of the Bulletin we revisit that grisly crime. We 
also join several alumni and faculty in looking at more recent crimes and the 
ways they were solved using forensic techniques both new and ancient. 

An issue on medical detectives must be quite selective, as all physicians are 
detectives at one time or another. Diagnosis is detection, and the affiliation of 
medicine with detective fiction is ever present. (You may recall that we meet 
Sherlock Holmes, the most famous of all fictional detectives, when two physi- 
cians join him in a laboratory, where he demonstrates an exquisitely sensitive 
method to detect blood stains. More about Holmes and his physician creator, 
Sir Arthur Conan Doyle, on the last page.) There's a certain breed of medical 
gumshoe, the shoe-leather epidemiologist, who shares both footwear and cer- 
tain investigative methods with the more classical form of detective. Two of 
these detectives also are featured in the current issue. 

How people wind up doing what they do is a mystery that can rarely be 
solved, but part of the intrigue of this issue is the occasional clue scattered in 
the life histories of its subjects. One of our epidemiological detectives read 
Microbe Hunters at a suitably impressionable age. At the same age, another was 
provided a cadaver to dissect by her mother. One of our medical examiners, 
who has a Holmesian turn of mind, noticed as a young boy the peculiar 
imprint left by coral striking flesh and would use that memory decades later 
to help solve a crime. And one of our authors, a physician turned historical 
essayist, defied maternal disapproval to attend HMS. More than a century 
after the Parkman murder, his mother worried that its legacy made the School 
unsuitable and unsafe for her son. There's the power of history. 

One thing is not a mystery about the Bulletin. This year we have received 
three national awards from CASE, the Council for Advancement and Support 
of Education: a gold medal to mark us as a leader among magazines published 
by professional and graduate schools, as well as those that cover research, sci- 
ence, and medicine; a gold medal for last summer's issue on music and medi 
cine; and a silver medal to recognize our recent changes in format. This recog 
nition is due to the editorial vision of Paula Byron, editor of the Bulletin: the 
reportorial skills of our associate editor, Phyllis Fagell; the lively writing of 
Beverly Ballaro, our assistant editor; and the artistic sensibilities of our design 
director, Laura McFadden. It is due also to the alumni whose articles in the 
Bulletin make it distinctive among publications of its kind. Thanks to all of you. 



EDI 1 OK IN CHIEF 

William Ira Bennett '68 

EDITOR 

Paula Brewer Byron 

ASSOCIATE EDITOR 

Phyllis L. Fagell 

ASSISTANT EDITOR 

Beverly Ballaro, PhD 

BOOK REVIEW EDITOR 

Elissa Ely '88 



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EDITORIAL BOARD 

Elissa Ely '88 

Robert XL Goldwyn '56 

Joshua Hauser '95 

Paula A.Johnson '84 

Perri Klass '86 

Victoria McEvoy 75 

JamesJ.O'ConneLl'82 

Gabriel Otterman '91 

Deborah Prothrow Stith 79 

Guillermo C. Sanchez '49 

J. Gordon Scannell '40 

Joshua Sharfstein '96 

Eleanor Shore '55 
John D. Stoeckle '47 

DESIGN DIRECTOR 

Laura McFadden 

ASSOCIATION OFFICERS 

Sharon B. Murphy '69, president 
Charles J. Hatem '66, president-elect 1 

Paul J. Davis '63, president-elect 2 

Stephen G. Pauker '68, vice president 

Maria C. Alexander Bridges '80, secretary 

James B. Field '51, treasurer 

COUNCILLORS 

Claire V. Broome 75 

Paul Farmer '90 

B. Lachlan Forrow '83 

Michael A. LaCombe '68 

Eric B. Larson 73 
Gina Moreno John '94 

Deborah J. Oyer '87 
De Wayne M. Pursley '82 

Morton N. Swart; '47 
Nanette Kass Wenger '54 

DIRECTOR OF ALUMNI RELATIONS 

Daniel D. Federman '53 

ASSISTANT DEAN FOR ALUMNI 
AFFAIRS AND SPECIAL PROJECTS 

Nora N. Nercessian, PhD 

REPRESENTATIVE TO THE 
HARVARD ALUMNI ASSOCIATION 

Chester d'Autremont '44 

The Harvard Medical .Alumni Bulletin is 

published quarterly at 25 Shattuck Street, 

Boston, MA 02115 ■ by the Harvard 

Medical Alumni Association. 

Phone: (617) 432 1548 > Fax: (617) -4 52 0013 

Email: bulletints'hms. harvard.edu 

Third class postage paid at Boston, 

Massachusetts. Postmaster, send form 3579 

to 25 Shattuck Street, Boston, MA 02115 

ISSN 0191 7757 • Printed in the U.S.A. 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 






.,.1 



SECOND OPINIONS FROM OUR READERS 



LETTERS!^ 



The Monkey and the Blue Dress 

Lewis Harness's article in the spring 1999 
issue of the Bulletin — "Pediatric Care Fifty 
Years Ago" — was superb. It brought back 
a flood of pleasant memories of long ago. 

I graduated from HMS in 1933, worked 
with Sidney Farber for three months on 
the pathology of transpositions, and then 
spent three months as an intern at the 
House of the Good Samaritan. In 1935, I 
began a pediatrics residency at Children's 
Hospital in Boston. 

At that time, the Good Samaritan only 
admitted patients with rheumatic fever — 
up to adolescence for males and at all ages 
for females. Unfortunately, the etiology of 
rheumatic fever was still obscure and there 
were no effective therapies. As Barness 
WTOte, sunshine and a warm climate were 
thought to be beneficial, and each winter 
the Good Samaritan would send some of 
the more severely afflicted children to a 
hospital in Florida. This treatment seemed 
to help until one year, when there was an 
epidemic of sore throats and many of those 
children had severe recrudescences, neces- 
sitating a quick return to Boston by train 
and bus, as there were no planes available. 

In those days, the sed rate was our final 
criterion for when a child could be excused 



from complete bed rest. The patients 
quickly realized this, and whenever I 
appeared with the IV tray, they would all 
immediately hold out their arms and beg, 
"Please stick me, please" — even down to a 
five-year-old girl, Virginia L, who had 
already had several attacks of rheumatic 
fever and was one of the youngest children 
ever admitted to the Good Samaritan. 

In the evenings, after the children had 
gone to sleep, the intern made "breathing 
rounds" — going from bed to bed listen 
ing to the pattern and frequency of each 
child's respiration — and tucking in oth- 
ers who were still awake. At that time, 
salicylates were pushed to subtoxic lev 
els in the hope that they might affect the 
disease and cardiac manifestations as 
they did the arthritis and fever (though 
not the chorea). The "breathing rounds" 
were to detect hyperpnea, one of the ear- 
liest signs of salicylate toxicity. 

The House of the Good Samaritan, its 
staff, and particularly its patients were the 
best educators I have ever had — educators 
in the sense of leading (or forcing) one to 
learn, to read, and to delight in advances 
in knowledge. These "lessons" have per 
sisted 66 years later, as has the awareness 
ot the deficiencies in our knowledge. 




A PLACE IN THE SUN: In the mid- 1930s, when this picture was taken, rheumatic fever 
patients at the House of the Good Samaritan would receive sun treatments. 



It is difficult to imagine today how 
close the bonds were between the staff 
and patients at the Good Samaritan, 
because the patients were there for such 
long periods of time. I am enclosing some 
doggerel that I composed at the Good 
Samaritan in late 1933. I wrote it for a 
young girl, Olive B., when T Duckett 
Jones transplanted a rheumatic fever nod- 
ule from her to a monkey to try to learn 
more about the disease. Olive had severe 
rheumatic fever — and a favorite blue 
dress. The delight she felt when I read the 
poem to her still affects me deeply, for she 
died a short time later. 

Ollie and the Monkey 



The time has eome, the interne said, 

To talk of many things. 
Of colds, and throats, and nodules firm 

And why the heart doth sing. 

That brings to mind, the doc opined, 

ThecascofOlUcB. 
The growth of lumps and fever high 

Isher propensity. 

One day anew, some nodules grew 

Upon her wrist and knee. 
Professors wise from miles around 

Did come, these lumps to see. 

\\ 'ith scalpel bright they long did fight 

This nodule: to dissect, 
And in a monkey named Old Tish 

The same small lump inject. 

The monkey vowed in cries quite loud 

The node was like a pearl; 
The node replied it could not tell 

The monkey from the girl. 

But I did strike — they're not alike' 
That statement is not true' 

The girl alone, and not the monk, 
Looks good when dressed in blue. 

"The heart doth sing" referred to our 
practice of telling the children that, when 
auscultating, we were listening to their 
hearts singing. 



SPRING 2000 • HARVARD MEDICAL ALUMNI BULLETIN 



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I LETTERS 



SECOND OPINIONS FROM OUR READERS 



In the summer of 1935, we had a severe 
polio outbreak, so the Bulletin's picture of 
the monster Drinker respirator also 
brought back many memories. At Chil- 
dren's Hospital, we used to go into the 
respirator — quickly to avoid interfering 
with the children's respiration — to 
examine and take care of the children. 
Once inside, the changes in pressure 
were hardly noticeable. Again there was 
no knowledge of the cause, treatment, or 
prevention of polio. 

One child, Helen R., was admitted 
with severe bulbar signs, high fever, and 
rapid pulse — signs of a quick and fatal 
outcome. Every time I tried to clear 
Helen's throat with a suction tube, she 
fought to exhaustion. It soon became evi- 
dent, however, that Helen would die 




from aspiration pneumonia unless we 
found a better way to prevent it. After 
much persuasion, to the point of being 
obnoxious, I convinced the staff to do a 
tracheostomy. At that time, no tra 
cheostomies had been done for polio at 
Children's Hospital, and had only been 
done sporadically elsewhere. The sur- 
geons insisted on doing the tracheostomy 
under local anesthesia. I well remember 
the fright of that poor child during the 
operation. Fortunately, she did not 
remember the operation afterward. Aspi- 
ration and pneumonia could now be pre- 
vented, and Helen recovered from both 
the tracheostomy and the polio without 
obvious sequelae. 

Before the tracheostomy tube was 
removed, I asked Helen if we could suction 
it before a camera, drinking we 
might be able to use the film to 
reassure parents of children 
with similar problems. The suc- 
tioning brought tears to Helen's 
eyes, but when it was finished, 

■ she gave a bright and unforget- 
table smile through her tears. I 
don't know whether the movie 
was ever used, but I'm sure that 
no one in that room ever forgot 
that tearful but happy smile. 

As the song goes, "thanks 
for the memories!" 

JEROME HARRIS '33 
DURHAM, NORTH CAROLINA 



Miracles on Binney Street 

Benedict Massell's letter to 
the editor in the autumn issue 
recalled poignant memories 
for me of the House of the 
Good Samaritan, Dr. Massell 
'31, Dr. T Duckett Jones, and 
the many children with active 
rheumatic fever. The year was 
1944, my junior year at HMS, 
when I served as a student 
intern with Tom Macklin, 
who was in his senior year. 
We made rounds twice daily 
and wrote all the orders on 
those 80-odd children, under 



the stimulating and wise counsel of Drs. 
Massell and Jones. 

Two memorable events took place dur- 
ing my tenure. One day having made 
rounds twice and ha\ing examined all the 
children, I sat down for dinner with Miss 
Hussey, RN — the director of the hospi- 
tal — and other staff members. She noted 
that I had a rash, which was quickly diag- 
nosed as measles. When notified. Dr. 
Jones immediately had me transferred to 
the Harvard Infirmary lest I endanger any 
more children. The records revealed that 
over half of the children had never had the 
measles. This potentially lethal crisis led 
Dr. Jones to contact authorities in Wash- 
ington responsible for the distribution of 
gamma globulin during the war. They 
immediately arranged to have this scarce 
plasma fraction shipped to Boston. Fortu- 
nately, all the children at risk were able to 
get the protection they needed and none 
developed measles. 

On another occasion, Bobby H., a four- 
year-old boy with severe rheumatic heart 
disease, developed acute bacterial endo- 
carditis with a temperature of over 105°. 
Dr. Jones prevailed on Chester Keefer, 
chairman of the Committee on 
Chemotherapeutics of the National 
Research Council — also known as the 
"pemcillin czar" — to release some pre- 
cious reserve from the wartime stockpile. 
Since pemcillin was in such short supply 
and was used primarily for the Armed 
Forces, little was available for the civilian 
population. With this gift of pemcillin, 
Bobby made a dramatic recovery. To my 
knowledge, he was the first child, if not 
person, to receive penicillin for the treat- 
ment of bacterial endocarditis. So scarce 
was penicillin at this time that attempts 
were made to extract it from the urine of 
treated patients and reuse it. 

This stimulating year at the Good 
Samaritan directed me into the field of 
rheumatic diseases. I was on the "lupus" 
team of physicians at Mt. Sinai Hospital in 
New York in the late 1940s. This was the 
first group in the United States to be given 
access to cortisone to perform clinical 
studies in the treatment of systemic lupus 



HARVARD MEDICAL ALUMNI BULLETIN ■ SPRING 2000 



HOUSE Of THf GOOD SAMARITAN, BOSTON 




WARTIME HEALING: The House of the Good Samaritan in 1944 



erythematosus. Chester Keefer again was 
responsible for the allocation of this new 
drug to research specialty groups 
throughout the country. Later, while 
doing biochemical and clinical research at 
the National Institutes of Health, I had the 
good fortune to work in the Bunim group 
when they were given the first and exclu- 
sive use of prednisone and prednisolone 
for clinical research in rheumatoid arthri- 
tis. These were exciting times with some 
of the early "miracle" drugs. 

When 1 returned to Boston for my 50th 
medical school reunion in 1995, 1 was sad- 
dened to learn that I could not re\isit the 
House of the Good Samaritan on Binney 
Street. It had been demolished years earlier. 

NORMAN F. BOAS '45 
MYSTIC, CONNECTK1 1 

Leveling the Playing Field 

I want to express my gratitude to the 
Bulletin for publishing the autumn issue 
with its tocus on progress in recruiting 
women and people of color to HMS, 
both students and faculty. I was keenly 
aware during my medical education and 
training that women and minority 
groups were vastly underrepresented 
and not always treated with respect. I 
have continued to be fully supportive of 
the goals of the civil rights and women's 
rights movements over the years, espe- 
cially as they have played out in affirma 
tive action programs. As more women 
and minorities enter medical practice, 
teaching, and research, the quality of 
care provided to women and minority 
persons is improving. As highlighted by 
both Derrick Bell and David Satcher, 



this nation still has a long way to go in 
leveling the playing field for all races 
and both sexes. I applaud the ongoing 
efforts of HMS to do just that in the field 
of medicine. 

I HOMAS WASH RURN '57 
BRADENTON, FLORIDA 

Alone Among the Ivys 

The autumn issue of the Bulletin remind- 
ed me of something I had read that made 
me proud of HMS. The July 22, 1999 
issue of Black Issues in Higher Education 
reviewed the standings of medical 
schools in relation to educating African 
Americans, Hispanics, Asian Americans, 
and Native Americans. 

Harvard is the only Ivy League medical 
school to appear on the list. We rank fifth 
for African Americans and second if you 
discount the three historically African 
American medical schools. The program 
held last June that celebrated 30 years of 
affirmative action at HMS would have 
been greatly enhanced if these data had 
been available. By making a conscious 
effort, we can make a real difference. 

We are 18th in educating Hispanics and 
15th in educating Asian Americans, again 
alone among the Ivys to be ranked. This is 
important information and should be 
made available to those communities w e 
want to target. 

JAY M. JACKMAN '64 
ITHACA, NEW YORK 

The Role of Students 

Some months ago, Ed Hundert '84 sug 
gested that I contact you about a historical 
question that the Bulletin's article on affir 



mative action at HMS in the autumn issue 
raised anew for me. Please let me know if 
you can help me clarify an issue about the 
sequence of events at HMS in 1968, when 
I was a second-year student. 

My recollection is that Noel Solomons, 
the only African American in the Class of 
1970, and I had petitioned Dean Robert 
Ebert, with the support of a number of fel 
low students, to address race issues at 
HMS. Dean Ebert, as was his style, 
responded appreciatively and appointed a 
"faculty commission" to pursue the sub- 
ject. Shordy thereafter, the assassination 
of Dr. Martin Luther King, Jr. led to the 
sequence of events described in the Bul- 
letin, and the "commission" either became 
or was replaced by the initiative of the fac 
ulty members mentioned in the Bulletin. 

The point I wish could be better made, 
with real evidence behind it, is not which 
individual students were involved at the 
time, but rather the reality that the stu- 
dents led the faculty on these matters, 
and the Bulletin article, as well as the 
plaque in the lobby of Building A at HMS, 
ignores this aspect of the story entirely. 
The point that students can influence 
events in the real world is one that 
Dr. Hundert agrees needs to be empha- 
sized for today's cohort of students. 

I have the highest respect and admira- 
tion for the HMS faculty who have been 
appropriately honored for their initia 
tives and accomplishments in this area. 
They were truly our inspiration academi 
cally, but if you ask them, I think they 
might concur that the students took 
more of the initiative than the now semi- 
official version of the history of that peri- 
od acknowledges. 

JOSEPH H. ALBECK '/O 
BELMONT, MASSACHUSETTS 

Standing Up for What Was Right 

I have read the article on "Thirty Years of 
Affirmative Action" in the recent Bulletin. 
I have also previewed the commentary by 
my classmate Dr. Joe Albeck, in which I 
have been correctly singled out as the only 
African American member of the Class of 
70. Depending upon whether you count 



SPRING 2000 • HARVARD MEDICAL ALUMNI BULLETIN 



SECOND OPINIONS FROM OUR READERS 



the 30 years from 1969 and the beginning 
of affirmative action at HMS, or the three 
decades of graduates to the end of the 
century, I am either at the top of the pyra- 
mid, or on the bottom of the totem pole in 
relationship to the affirmative action era. 
To read the article in the recent issue of 
the Bulletin, it would almost seem as if Mar- 
tin Luther King, Jr. died so that 717 minori- 
ty graduates of the dental and medical 
schools might live, and matriculate. A 
score and twelve years can put a lot of haze 
into the memory of the primary protago- 
nists around the affirmative action resolu- 
tion, but martyrdom was not 
really the key. Should one credit 
the faculty proposers or the stu- 
dent activists of the era? Or most- 
ly the general tenor of the tumul- 
tuous times? The civil rights 
movement was in motion, linking 
blacks and whites together in a 
common struggle. It was also the 
era of African decolonization, 
Kwame Nkrumah's Negritude, 
and the formation of the Black 
Panther party, all of which 
brought blacks together around 
our common experience. 

I had balanced both move- 
Martin 

ments during my time at Har- speech 
vard College, but on Longwood 
Avenue, the critical mass of African 
American students had not arrived to 
foster what has become the Coleus Club. 
So, indeed, it was a need for "inclusion" of 
more persons of color — that is, to pro- 
vide access and justice for an oppressed 
underclass — that motivated and justified 
the resolution. (The "diversity" ratio- 
nale — that it helped others to attend 
classes with "others," an idea derived 
from James Baldwin's essays — had not 
yet joined the argument.) 

In the historical discussion of affirma- 
tive action, let it not be forgotten that 
fewer than a dozen women entered HMS 
in 1966. Kate Millett's Sexual Politics, pub- 
lished in 1967, may have raised the con- 
sciousness to recognize another degree of 
narrowness in the selection of Harvard's 
student body. 



In the late 1960s, good men and 
women were standing up for what was 
right in all institutions. As I remember it, 
the nine faculty sponsors had also taken 
personal and collective stands against the 
Vietnam War. We can be indebted to 
these men for making their stand in the 
faculty meeting in 1968. Indeed, there 
was a deep and broad ferment of student 
consciousness on the Quad that fed from 
the times (and fed into the times), and 
linked the evidence of exclusion and 
injustice with the opportunity for its 
redress. That is what we are acknowledg- 




Luther King, Jr. delivering his 
on August 28, 1 963 



'I Have a Dream 



ing — I hope not with too much self-con- 
gratulation — in the 30th anniversary of 
an important milestone in the history of 
our alma mater. 

NOEL W. SOLOMONS '70 
GUATEMALA CITY, GUATEMALA 

Faculty Members Respond 

Joseph Albeck recalls correctly that a stu- 
dent petition carrying 278 signatures was 
presented to Dean Ebert in May 1968 and 
resulted in the appointment of a Harvard 
Medical School Commission on Relations 
with the Black Community in Boston. 
One of our group, Leon Eisenberg, as 
chair of that commission, reported its 
findings to the faculty in April 1969. 

Dr. Albeck confuses that action, how- 
ever, with a parallel but independent ini- 
tiative undertaken by Jonathan Beckwith 



and Edward Kravitz, who with seven 
other colleagues drafted a petition urging 
a commitment to admit 15 disadvantaged 
students each year. That petition was pre- 
sented at the April 1968 Faculty \ leering 
and was voted on affirmatively at the May 
1968 meeting (the same one at which the 
commission was established). Neither 
action "replaced" the other. The history of 
these events was described briefly in the 
Fall 1990 issue of the Bulletin. 

We agree that we were stimulated, 
strengthened, and inspired by student 
activism. Noel Solomons is absolutely right 
in linking the general tenor of the 
times, the civil rights movement, 
the era of African decolonization, 
and other political forces to the 
action taken by the H\ IS faculty. 
Noel himself was invaluable in 
assisting us as we planned a strat- 
egy to secure faculty support. 

To "credit" either the faculty 
sponsors or the student petition 
signers alone with the success of 
affirmative action at HMS over- 
looks the many indhiduals and 
forces at work. The Reverend 
King did not die "so that" minori- 
ty students could matriculate at 
HMS. But his fight against racism 
and his assassination were pivotal 
events in making white Americans recog- 
nize the enormity of the injustices inflicted 
on minorities. It created a climate in which 
even those faculty members who were 
dubious about the propriety of affirmative 
action felt it necessary to vote for the policy 
because our country seemed to be careen- 
ing toward self-destruction. 

Let us join Drs. Albeck and Solomons in 
remembering an important milestone in 
the history of HMS by situating it in the 
larger context of the times. Better yet, let 
us call for renewed efforts by students and 
faculty against the exclusion and injustice 
that still persist in our health care system 
and in our academic institutions. 

LEON EISENBERG, MD 
JONATHAN BECKWITH, PHD 
EDWIN FURSHPAN, PHD 
EDWARD KRAVITZ, PHD 
BOSTON, MASSACHUSETTS 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 



Surgeon General's Warning 

In your autumn issue, you quoted Sur 
geon General David Satcher as stating, 
"Only one third of physicians even ask 
their patients whether they smoke, let 
along recommend that they stop." Five 
years ago, I told my wife and one of my 
sons that smoking might kill them. My 
35 year old son listened to me and never 
touched another cigarette. My wife just 
laughed and continued smoking. One 
year ago, she was diagnosed with cancer 
of the lung with metastasis. She never 
touched another cigarette. But it was too 
late, and she died. 

CHARLES H. BAUER '53 
NEW YORK. NEW YORK 

Learning from the Masters 

The wonderful and moving tribute that 
George Richardson '46 wrote about his 
brother Edward Peirson (E.P.) Richardson 
'4 3 A in the Spring 1999 issue brought back 
many fond memories. 

I first became interested in neurology 
during first year neuroanatomy, when Ray 
mond Adams, E.P., and others lectured to 
us, and we dissected formalin- treated 
sheep brains (scrapie free, I hope!). In sec- 
ond-year neuropathology, the same cast of 
characters appeared to help us discriminate 
disease from normality in the neuropath 
lab, where the huge glass slides of brain sec- 
tions — many "slices" from "brain cuttings" 
at Massachusetts General Hospital and 
Boston City Hospital — brought home the 
cellular life of the brain and spinal cord, and 
the effects of rabies, polio, encephalitis, and 
other diseases. These lectures captured my 
imagination and held it forever. 

During third and fourth year, there 
were the clinics at MGH, headed by 
Vincent Perlo, who could turn my clini- 
cal findings on a new patient into a rare 
hereditary disease — Friedreich's atax- 
ia — right before my wondering eyes. By 
the time of residency at MGH, we rotat- 
ed on neurology, and watched C. Miller 
Fisher exhaustively examine a patient, 
as he did an intellectual CAT scan by 
piecing together the tidbits of abnor 
malities he found. 



At the weekly "Brain Cutting" on Fri 
days, E.P. held sway, gravely hstening to 
the clinical presentation before he cere- 
moniously and sacredly removed the 
dripping, uncut brain from the glass jar 
recking of formaldehyde. Like a famous 
poultry chef, he took the razor-sharp, 
long, flat, stainless blade and cut 
through the brain with breadloaf- cut 
ting precision, commenting like an 
archeologist on the findings as he passed 
through layer after layer. A reverent 
silence in the group of ten to fifteen fac- 
ulty, neurology residents, rotating med- 
ical residents, and others sitting at the 
conference table allowed his quiet voice 
to enter each living brain in the room. It 
was a magical and mystical performance 
from a man who knew what he loved in 
the world of medicine, and spoke care- 
fully measured words as he revealed the 
mysteries of the diseases of the brain to 
those in attendance. 

At other times, I saw E.P. m the library, 
which was a haunt of mine when I finally 
reached faculty level. He was often there 
when I was there, but on many occasions 
he seemed to be either catching up on his 
sleep in the comfortable seats of the old 
Treadwell or thinking out some abstruse 
problem. Like so many others, I held E.P. 
in esteem, and learned as the years went 
by that he had a boyish enthusiasm hid 
den beneath his quiet ways, an enthusi 
asm that propelled him dowTistairs two 
steps at a time in the Baker Building 
stairwells, where I dodged him when I 
was on the way up. 

I like to think that E.P.'s sailing adven- 
tures took him past many lighthouses. 
Like so many others in my medical career 
at MGH, E.P. was a beacon to me, and his 
light shines on. 

NEWTON HYSLOP '6l 
NEW ORLEANS, LOUISIANA 

The Bulletin welcomes letters to the editor. Please 
send letters by mail (Harvard N ledical Alumni 
Bulletin, 25 Shattuek Street. Boston, Massachu- 
setts 02115); fax (617-432-00J3); or email (bid 
letin@hms. har\'ard.cdu). Letters may be edited for 
length or clarity. 



SAVE THE DATES 



Alumni Events to 
Mark the Millennium 

The Harvard Medical Alumni Council 
invites you to keep up with the 
School's latest research, education, 
and clinical medicine by attending a 
special two-part seminar. "HMS at the 
Millennium: What's New and What's 
Happening In and Around the Quad- 
rangle" will take place at HMS on 
October 20 from 3:00 to 5:30 p.m. 
and October 21 from 10:00 a.m. to 
12:30 p.m. Featured speakers will 
include Dean Joseph B. Martin, Judah 
Folkman '57, Philip Leder '60, Peter 
Black '66, and Paula A. Johnson '84. 
CME Category 1 credit is available. 

For more information, contact Tcnky Albright 'o! 

(617 247 8202; TcnleylOOmiol.com), or visit 
www.hmsharvard.edu OnThcThcsholdimkxhml 




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SPRING 2000 • HARVARD MEDICAL ALUMNI BULLETIN 



A 



PTIT,SF, 



MAKING THE ROUNDS AT HMS 





The Second Year Show 



EMBERS OF THE CLASS OF 2002 

sang, stomped, and step- 
danced their way through 
the second year show, "Per- 
verse Transcriptase." 

The show detailed the hunt for a retro- 
virus that had run amok. Students in the 
New Pathway tutorial group and the 
Division of Health Sciences and Technol- 
ogy embarked on a quest to save their 
classmates and professors from being 
transformed by the virus into "former 
incarnations and latent fantasies." While 
on that mission, the class lampooned life 
at the medical school through skits and 
parodies of popular songs. 

To the tune of "One Day More," from 
the Broadway musical "Les Mis- 
erables," students sang: "One block 
more, eight more weeks of agony, then 
Christmas break and I'll be free." 

In "Gastrulate," sung to Kool and the 
Gang's "Celebrate," students portraying 
embryology lecturers Elizabeth Hay, 
Roslyn Orkin, and Betsey Sampson 
Williams belted out: "We've got our 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 




endoderm and ectoderm, \ 
coming together to make con- 
ception firm." 

For "Dan Is from Mars, Elio Is 
from Italy," students George Dyer 
'02 and Brady Case '02 highlighted the 
different teaching styles of anatomy pro 
fessors Daniel Goodenough and Elio 
Raviola. In another scene, "The HMS 
Love Boat," Judah Folkman '57, professor 
of anatomy and cellular biology, was por- 
trayed as a combination cruise doctor 
and lounge singer. And in "Smooth 
Obturator," Suzie Brown '02 portrayed 
Cynthia McDermott, a lecturer in the 
anatomy course, singing passionately 
about the pelvis to Sade's song "Smooth 
Operator." 

"The show was an amazing experi 
ence," says Joyce Liu '02, one of the four 
producers. "Most of the class was involved 
in some way. We supported each other, 
and everyone put so much effort into it." 

The Class of 2002 expects to donate 
more than $5,000 from the proceeds to 
charity. ■ 




CLASS CLOWNS: Above: Suzie Brown '02 
assumes the identity of Cynthia McDer- 
mott, a lecturer in the anatomy course; 
below: Wilson Liao '02 impersonates 
Daniel Federman '53; and left: Jason 
Williams '02 portrays Judah Folkman 
'57 as a combination cruise doctor and 
lounge singer. _ 






Linking Biodiversity to Health 




RIC CHIVIAN '68, DIRECTOR 
of the Center for Health and 
the Global Environment at 
HMS, is championing biodi 
varsity from a doctor's perspective. He 
has secured a commitment from the 
World Health Organization and the 
United Nations Environmental Program 
to launch an international scientific 
effort to document the 
impact of species loss and 
ecosystem disruption on 
human health. 

The project — "Biodi- 
versity: Its Importance to 
Human Health" — is to be 
implemented over a three- 
year period. It will culmi- 
nate in the most compre- 
hensive report yet about 
how biodiversity affects 
human health, including 
an assessment of policy 
options. Chiviaris goal is 
to establish a sustainable 
framework so the report 
can be repeated every five 
years. Although interest 




in understanding the link 



between human health 
and global environmental change has 
been growing since the Earth Summit in 
Rio de Janeiro in 1992, no other attempts 
have been made to establish a regular, 
coordinated process to analyze this issue 
in the context of biodiversity loss. 

"One of the greatest problems we 
face," Chivian says, "is that most people 



GUARDING THE FUTURE: 
Eric Chivian '68 is spear- 
heading an international 
effort to document the effect 
of biodiversity on health. 



still see themselves as separate from the 
environment, and therefore are not moti 
vated enough to do what is necessary to 
preserve it." 

Medical pharmaceuticals and research 
both rely heavily on other species, Chi- 
vian explains. Taxol, for example, one of 
the most promising medications to treat 
breast and ovarian cancer, is derived 
from the once threat 
ened Pacific yew tree. 
Overfishing continues to 
endanger some shark 
species that are valued 
for the insight they pro- 
vide in the study of 
immune function. 

Furthermore, ecosys- 
tem disruption may lead 
to the emergence of some 
infectious diseases. Stud 
ies have linked the 1993 
hantavirus outbreak in 
the southwestern United 
States, for example, to 
extreme weather that 
increased local popula 
tions of the virus-carry 
ing deer mouse. 

Although still in the 
planning stages, the project already has 
had an impact. The center has been invit 
ed to submit its findings to the Conven- 
tion on Biological Diversity, the United 
Nations effort organized to set interna- 
tional policy for the protection and 
preservation of species and habitats 
around the world. ■ 



Keeping the Tradition 

For the 1 1th year in a row, HMS topped the U.S. News and World Report 
medical school rankings. 

In the listings by specialty, HMS was rated first for internal medicine, women's 
health, geriatrics, and pediatrics. The School was listed second for AIDS and 
sixth for drug and alcohol abuse. HMS was also ranked second in the primary 
care category. 

The results are based on four criteria: reputation (40 percent); research activity 
(30 percent); student selectivity (20 percent); and faculty resources (10 percent). 
The complete list can be found on the U.S. News website (www.usnews.com). ■ 



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SPRING 2000 • HARVARD MEDICAL ALUMNI BULLETIN 



PRESIDENT'S REPORT 




HE ALUMNI COUNCIL CON- 
ducted an experiment by 
holding its first-ever out of 
town meeting. We invited all 
HMS alumni from the Washington/Bal 
timore area to join us for a town meeting 
at the National Library of Medicine in 
Bethesda on March 17 and 18. Our goals 
were to strengthen links with local 
alumni and to provide the talented alum- 
ni in the area with an opportunity to 
share their views with the Council and 
the HMS administration. 

We began with a stimulating panel dis- 
cussion led by Daniel Federman '53 and 
enlivened by interaction from the partici- 
pants and alumni in attendance. The pan- 
elists were Jordan Cohen '60, president of 
the American Association of Medical Col- 
leges; Steven Hyman '80, director of the 
National Institute of Mental Health; Ken- 
neth Shine '61, president of the Institute of 
Medicine; and Barbara McNeil '66, chair 
of the Department of Health Care Policy 
at HMS — a distinguished group indeed. 

Cohen presented us with a "good 
news/bad news" summary of the current 
state of medical education. He pointed out 



that medical schools continue to attract 
high quality- applicants nationwide, but 
that issues of student debt and lack of 
diversity require attention. He also high 
lighted the current tensions between pro- 
fessionalism and commercialism in acade- 
mic medical centers. The shift in teaching 
from the hospital to the ambulator) 7 envi- 
ronment is a problem, Cohen added, as is 
the time pressure on teaching faculty. 

Hyman provided an interesting per- 
spective from the National Institute of 
Mental Health, which has been blessed by 
significant appropriation increases from 
Congress over the past few years. The 
institute, he said, now desperately needs 
to bring basic and clinical researchers 
together in translational research endeav- 
ors, which often require a large interdisci- 
plinary research team for success. 

McNeil pointed to the multidiscipli- 
nary nature of health policy research at 
Harvard, which, she said, is conducted 
with the input of experts in medicine, 
economics, statistics, sociology and 
informatics. What, she asked, should 
HMS and its hospitals be doing to ensure 
quality of care? 




ON THE ROAD: Above, from left: Daniel 
Federman '53; Maria Alexander-Bridges 
'80; Gina Moreno-John '94; Sharon 
Murphy '69; Henry Chang '69; and 
Bryan Arling '69; right: Tenley Albright 
'61 and her husband, Jerry Blakeley 



Shine discussed the role of physicians 
in creating systems of care, emphasizing 
the need to train physicians in systems 
development, informatics, and outcome 
analyses — not areas in which physicians 
are generally schooled. He stressed that 
quality can be the lever by which physi- 
cians can regain their professionalism, 
and he predicted that third- party payers 
will increasingly value quality, not just 
lowered costs. 

After a luncheon and remarks by 
Joseph Martin, dean of HMS, the Council 
continued an open meeting. Jules Dien 
stag, HMS faculty associate dean for 
admissions, spoke about the demograph- 
ics of the incoming class. .After a report by 
Tenley .Albright '61, chair of the .Alumni 
Fund, we toured the National Library of 
Medicine, a remarkable national resource 
that most of us had never \isited. 

The day proved most enjoyable and 
satisfied a yearning many of us feel to be 
part of a professional community. Our 
only regret was that more local alumni 
could not attend. If we take the Council 
on the road again, we will redouble our 
efforts to connect with local alumni for 
both their benefit and the good of HMS. 
Bryan Arling '69 led a local committee 
of alumni in expressing appreciation to the 
Council for holding its meeting in the 
Washington area. "Here, as throughout 
the country, many doctors are experienc- 
ing angst, alienation, and frustration," 
Arling said. "A wonderful antidote to these 
feelings would be to attend one of these 
Council sessions. HMS obviously contin- 
ues to strive for excellence and to seek 
ways to improve the way it trains its 
students, cares for its patients, and 
relates to its alumni. Watching our 
Council at work is exhilarating and 
inspirational." 

I hope to see you all in June to 
celebrate Alumni Week and the 
"Harvard Medicine at the Millen- 
nium" events. ■ 

Sharon B. Murphy '69 is chief of the Divi- 
sion of Hematology, Oncology at Chil- 
dren's Memorial Hospital in Chicago. 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 



BOOKS BY OUR ALUMNI 



BOOKSHELF 





Doctors 




The Search for Mental Health 

A History and A lavoir oj the \\ odd Federation for 
\ [enrol Health, 1948-1997, by Eugene B. Brody 
'44 (Lippmcott. \\ Warns & W Whins, 1999) 



This history follows the development of 
the World Federation for Mental Health 
from the end of World War II to its 50th 
anniversary in 1997. Brody illuminates 
the evolution of scientific understand 
ings of health and illness, the federation's 
efforts to reduce the stigma of mental ill 
ness, and the unique circumstances that 
have kept a nationally, culturally, and 
professionally diverse group of people 
working together for the common ideal 
of positive mental health. 

Doctors Afield 

Edited by Mary G. McCrea Curnen, 
Howard Spiro '47, and Deborah St. 
James (Yale University Press, 1999) 



This book examines the lives of 27 physi- 
cians who have combined the art of heal 
ing with other pursuits, such as art, writ 
ing, music, and politics. The doctors pro- 
filed include a toymaker, a wine grower, 
an astronaut, and a cabaret singer. Their 
testimonies reveal how integrating med- 
icine with other endeavors can provide 
physicians with inspiration and new 
energy to care for and relate to patients. 

Treating Emotional Disorder 
in Gay Men 

by Martin Kantor '58 (Praegcr, 1999) 

Kantor's book offers guidance to help 
therapists create effective, gay aware 





Obsessive- 
compulsive 












l*»M—« 




treatment plans. He argues that gay men 
with psychological problems have fallen 
through the cracks thanks to opposite 
yet equally unsatisfactory approaches: 
one that views homosexuality as patho 
logical and attempts to cure it, and 
another that attributes most of the prob 
lems of gay men to the negative effects of 
homophobia. In Kantor's view, both 
angles overlook the reality that gay men 
enter treatment with many ol the same 
therapeutic needs as everyone else. 

Obsessive-Compulsive and Related 
Disorders in Adults 

A Comprehensive Clmieal Guide, by Lorrin X 1 . 
Koran '68 (Cambridge University Press, 1999) 



Intended as a practical guide for psychia 
trists and other mental health profession 
als, this book presents in detail the diag- 
nosis, clinical picture, and pharmacother 
apeutic and psychotherapeutic treat 
ments for obsessive-compulsive disor 
ders. Treatment planning guidelines are 
given, and an extended chapter details the 
use of all medications that have been 
reported to be effective for these disor 
ders, along with the management of drug 
interactions and side effects. 

Illness and Health in the Jewish Tradition 

\\ Wrings from the Bibk to Today, by David L. 
Freeman '69 and Judith Z. Abrams, Edi 
tors (The Jewish Publication Society, 1999) 

In this anthology of Jewish reflections, 
writers offer their perspectives on 
health, illness, and recovery. The authors, 
who include doctors, scholars, rabbis. 



and poets, address topics such as the role 
and duties of the physician, the role of 
prayer in healing, and the ethics of care- 
giving. They also examine key philosoph- 
ical questions such as whether suffering 
and loss have larger meaning, and what 
the proper roles of secular and spiritual 
healers may be. 

Vascular and Interventional Radiology 

by Karim Valji '82 (W. B. Saunders Co., 1999) 



This introductory textbook, written for 
residents and fellows of radiology, is 
divided into three sections. The first 
emphasizes patient care before and after 
procedures. The second discusses the 
diagnosis and treatment in specific arteri 
al and venous beds. The third presents 
non-vascular intervention. The book con- 
tains both traditional and state-of-the-art 
imaging, and includes a discussion of the 
newest innovations in the radiology field. 

Diva 

by Rafael Campo '92 (Duke University 
Press, 1999) 



In Diva, his third book of poetry, Campo 
revisits his favorite themes. Writing 
about his patients, his Cuban heritage, 
and his sexual identity, he blends pop 
culture and classicism, humor and 
pathos, beauty and gritty realism. From 
poems that form a satirical dialogue 
between the voices of AIDS and 
monogamy, to a series of prose poems on 
birthing, Campo's book illustrates how 
writing has helped sustain his sense of 
empathy in his medical practice. 



SPRING 2000 • HARVARD MEDICAL ALUMNI BULLETIN 11 



BENCHMARKS 



DISCOVERY AT HMS 



Digital Age: Evidence Points to a Genetic Expansion Behind Vertebrate Fingers and Toes 




HE EVOLUTIONARY TRANSITION 

from life in the sea to life on 
land might have been nudged 
by a genetic expansion, 
according to an article published in the 
February 2000 issue of Development. HMS 
researcher Susan Dymecki and her col- 
leagues suggest that a gene previously 
expressed in the developing brain may 
also have come to be expressed in the 
tips of growing limbs, helping to bring 
about the development of fingers and 
toes in the first vertebrates. 

"So the idea is you get expansion of 
gene expression — not expression of a 
new gene — just expansion to a new 
area," says Dymecki, HMS assistant pro- 
fessor of genetics. She and colleagues 
Scott Baur and Jia J. Mai have recently 
identified both the structure of a gene 
and a genetic switch that could have 
brought about such an expansion. 

Until recently, the gene, which codes 
for a receptor found in the brains and 
skeletons of all vertebrates living today, 
was thought to be controlled by a single 
switch, or promoter. If that were true, a 
defect in the promoter should affect 
expression in the brain as well as the 
skeleton. But the researchers found that 
while mutant mice carrying such a defect 
lacked fingers and toes, their brains 
appeared, for the most part, normal. 

Two's Company 

On closer inspection, the researchers 
found that there was not one but two 
promoters, one controlling gene expres- 
sion in the brain, the other, which car- 
ried the mutation, controlling expres- 
sion in the limbs. The defective promot- 
er was farthest away from the gene. 
"This is the first time anyone has seen 
this distal promoter," Dymecki says. 

She and Baur, a graduate student, sug- 
gest that this distant promoter may have 
evolved more recently, perhaps as a result 
of a duplication of the one lying closer to 



the gene. Once formed, the new promot- 
er may have accumulated mutations that 
enabled it to interact with transcription 
factors found in developing limb cells. As 
a consequence, the receptor previously 
expressed in the brain would have come 
to be expressed in the limb buds. 

"This is speculation at this point — we 
could be wrong," Dymecki says. "But it 
could also lead to some exciting science." 
Baur is currently comparing the two pro- 
moters to see if he can find signs of a 
duplication. If so, it would suggest that 
the origin of life on land could have 
entailed not just the invention of new 
genes, but also putting old ones to new 
uses. It is a process nature has used many 
times before, Dymecki says. 



The Hox genes, which were first 
found to regulate body shape in flies and 
are now known to regulate body and 
limb development in vertebrates, are 
thought to have produced their wide 
variety of evolutionary effects by being 
expressed to different extents at differ- 
ent times and places in different animals. 
Similarly, the newly discovered promoter 
may have played a role in bringing about 
the diversity of vertebrate digits — from 
the frog's grasping toes to the stubbier 
toes of a human — by the timing and loca- 
tion of receptor gene expression. 

"These are things we're still fleshing 
out," Dymecki says. "It's been a real whirl- 
wind just to get this paper out." In fact, 
their paper appeared in Development along 




A GENETIC SWITCH: Comparisons of the embryos of normal and mutant mice by Susan 
Dymecki and her colleagues are yielding clues to limb development and evolution. 



12 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 



/ \ / \ 



with a paper by a group at UCLA. The 
California researchers knocked out the 
receptor gene in a strain of mice. Intrigu- 
ingly, the knockout mice exhibited the 
same phenotype as the HMS mutants. 
They lacked digits but their brains 
appeared normal. One possible explana 
tion for the masking of effects in the brain 
is that the receptor may play such an 
important role there that nature has pro- 
vided a genetic backup to make sure that 
its job gets done. 

Accidental Scientist 



If it hadn't been for a twist of nature, 
Dymecki and her colleagues might never 
have identified the second promoter. Her 
whole excursion into skeletal develop 
ment "was definitely serendipity," she 
says. In the course of studying brain devel- 
opment — her primary interest — Dymec- 
ki had generated a series of transgenic 
mice, each with a piece of DNA wedged 
into a different part of the genome. When 
she and her colleagues tried ear tagging 
one strain, they discovered that the mice 
were unable to grab the tabletop. 

It turned out the mice had failed to 
develop digits. Suspecting that the piece 
of DNA had inserted itself into the mid 
die of a gene for skeletal development, 
the researchers homed in on the gene, 
which produces IB bone morphogenetic 
protein receptor (BMPRIB). The protein 
was known to play a role in skeletal 
development, specifically the laying 
down of the cartilaginous blueprint that 
eventually develops into the bony skele 
ton. But no one had actually mapped out 
the structure of the gene (BmprlB) — that 
is, how exactly it is broken up into func 
tional units, or exons. 

After identifying the structure of 
BmprlB, Baur was able to determine that 
the chunk of DNA had become integrat- 
ed, essentially knocking out what 
appeared to be the promoter. The lack of 
any apparent defect in the brain of the 
mutant — at the time they did not know- 
that even knockouts show no brain 
defects — led them to look for a second 
regulatory element. 




Many bones, including the digits of the hand and foot, develop from 
a cartilaginous blueprint laid down in early development (top panels). 
During development, cells destined to become cartilage aggregate 
loosely, then condense and proliferate to form the blueprint for the adult 
skeleton. In mutant mice carrying the defective BmprlB promoter, the 
cells destined to form the digital cartilage neither condensed nor prolif- 
erated normally (top left). Consequently, adult mutant mice failed 
to form phalanges (bottom left). Susan Dymecki and Scott Baur suggest 
that BMPRIB, interacting with the protein GDF5, may send signals to 
genes involved in the condensation and formation of digital cartilage. 
In addition, BMPRIB and GDF5 may act independently of each other 
to promote the segmentation of cartilage into individual phalanges. 



Dymecki and her colleagues plan to 
use the transgenic system to see exactly 
how the limb -region promoter turns on 
BmprlB during mouse development — in 
which cells and at what times. Compar- 
ing BmprlB regulation in mice and other 
animals could provide a prehminary step 
toward understanding how the extraor 
dinary array of land- dwelling adapta- 
tions have evolved in different species. 



"We want to understand what regulato- 
ry elements are involved and what the evo- 
lutionary implications of those elements 
are in terms of species-to-species variation 
in digit formation," Dymecki says. "It does 
make me chuckle that it all came out of a 
simple transgenic insertion." ■ 

Misia Landau is the senior science writer for 
Focus. 



SPRING 2000 • HARVARD MEDICAL ALUMNI BULLETIN 



13 



■\ 



M 



iEDICAL 
TECTIVES 



14 



Forensic detectives are bringing 

new scientific tools into the courtroom to 

unlock decades-old secrets 



MARY THERESA BURHOE WAS 14 WHEN SHE WAS 

stabbed more than 100 times. Her body was dis- 
covered days later in the tall grass of a playground 
near her Boston home, her chest so mutilated that 
authorities at first assumed a shotgun blast had 
killed her. For nearly 20 years, the brutal crime 
remained unsolved. But now, cutting- edge tech- 
nology has helped police restart the investigation 
and file charges. 

"Not only are closed cases being reopened 
because of scientific advances, but cold cases are 

by Phyllis L. Fagell 




HARVARD MEDICAL ALUMNI BULLETIN ■ SPRING 2000 





he telling detail may come from a single strand of hair. 



being reinvestigated," says Frederick R. 
Bieber, associate professor of pathology 
at HMS. The prosecution has consulted 
Bieber about DNA evidence related to 
Mary Theresa's death. 

Shortly before the murder, Patrick 
Durham, the chief suspect, allegedly put 
a knife to the girl's throat and threatened 
to kill her. But without current DNA 
technology, prosecutors could not 
obtain a murder indictment. Now, 
decades later, a bloody bandage taken at 
the time of the crime from Durham has 
taken on new importance. Using the lat- 
est technologies, investigators compared 
the DNA found on the bandage with evi- 
dence from the crime scene. According 
to David Meier, chief of homicide in the 
Suffolk County District Attorney's 
office, the DNA evidence "conclusively 
links" Durham to the slaying. 'As a result 
of various evidence presented to a grand 
jury over the last several months," he 
says, the defendant was indicted in Jan- 
uary for first degree murder. 

"I often think about the overwhelm- 
ing number of unsolved cases that could 
benefit from the scrutiny of forensic sci- 
entists using the latest techniques," says 
Bieber, who also is a member of the 
DNA Advisory Board of the Federal 
Bureau of Investigation and of the Royal 
Canadian Mounted Police. "There are 
so many cases in which detectives have 
suspected a certain individual, but just 
haven't had adequate tools and technol- 
ogy to evaluate trace physical evidence." 

DNA evidence can also have near- 
irrefutable exculpatory power. The 
chances of a coincidental match are 
"vanishingly small," says David Page '82, 
chair of the Whitehead Task Force on 
Genetic Testing and Public Policy. 
Through the task force. Page has been 
bringing news about genetic discoveries 
to diverse audiences, including judges. 
"The impact of the human genetics rev- 
olution will be tremendous," he says. 
"The well-known forensics applica- 
tions of genetic testing are only the sim- 



plest part of the revolution that judges 
will have to grapple with in the future." 
Broader discussions will revolve around 
questions of public policy, he explains, 
because the technology itself has 
become so sophisticated and reliable. 

These days, in fact, even trace 
amounts of genetic material may pro- 
vide investigators with answers about a 
suspect's involvement in a crime. The 
telling detail may come from a single 
strand of hair clutched in the hand of a 
murdered elderly woman, or from 
epithelial cells found under a rape vic- 
tim's fingernails. 

And, as tests have improved, these 
microscopic bits of evidence are taking 
center stage in trials. When DNA analy- 
sis provides a particularly dramatic 
clue, Bieber says, "a pin drop can be 
heard in the courtroom." 

He recalls one high-profile case, 
which involved the 1994 shooting death 
of Massachusetts State Police Trooper 
Mark Charbonnier. Charbonnier had 
pulled over a van being driven by the 
defendant, David Clark. The defense 
raised the theory that Clark might have 
picked up hitchhikers who had actual- 
ly shot the officer. 

"The members of the jury were clearly 
riveted by the testimony of every expert 
witness," Bieber says. Most dramatically, 
the DNA analysis of the crime scene evi- 
dence supported the prosecution's con- 
tention that only two people, the victim 
and the defendant, were at the crime 
scene, and the jury convicted Clark. 

A Long History 

Forensic medicine received its first 
major boost more than 100 years ago. 
During the 1880s, the same decade that 
London novelist and physician Sir 
Arthur Conan Doyle created the 
world's most famous detective, Sher- 
lock Holmes, Scottish physician Henry 
Faulds published a letter in Nature that 
triggered modern fingerprint analysis. 



The individuality of human finger- 
prints had long been recognized, but 
the debate in Mature led an English sci- 
entist, Sir Francis Galton, to study 
them seriously. Another major break- 
through came in the early 1900s, when 
an Austrian physician, Karl Landstein- 
er, standardized the blood grouping 
system, and police and prosecutors 
realized that blood testing could help 
them solve crimes. 

"In the past," says Bieber, "biological 
evidence was characterized using either 
serologic testing to determine blood 
types, or isoelectric focusing to subtype 
certain protein components of blood. 
There's nothing wrong with this kind of 
testing, but it's much less discriminat- 
ing, and it has less exculpatory power." 

Other medical techniques also have 
been used in the past to solve crimes, 
Bieber points out, including microscop- 
ic hair comparison testing and morpho- 
metric skeletal analysis, a technique 
that is still used today to provide impor- 
tant clues about a victim's age, sex, 
height, and racial characteristics. 

An Ocean Apart 

Despite these advances, it is the last 15 
years that have truly revolutionized 
courtroom science. Once considered 
highly esoteric, technical phrases such 
as "restriction fragment length poly- 
morphisms" (RFLP) and "polymerase 
chain reaction" (PCR) have now 
entered the mainstream media. 

In the mid-1980s, huge scientific 
leaps in forensic medicine were made on 
both sides of the Adantic. In England, 
Alec Jeffreys, a young geneticist at the 
University of Leicester, constructed a 
set of radioactive probes that allowed 
RFLP methods to reveal what he 
referred to as a "genetic fingerprint." 
RFLP methods rely on inherited differ- 
ences in the lengths of DNA fragments 
produced after cleavage of DNA with 
restriction enzymes. Jeffreys marked 



16 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 




the different-length segments with the 
probes and exposed them on x ray film, 
where they formed a pattern of black 
bands — the "fingerprint." If the DNA 
profiles produced from two different 
biological samples matched, he conjec- 
tured, they probably came from the 
same person. 

The dramatic impact of Jeffreys's 
work became evident in 1986, when it 
excluded a 17- year old boy in the nearby 
village of Narborough who had con- 
fessed to the sexual assault and murder 
of a teenage girl. The boy was the first 
accused murderer to be set free as the 
result of a DNA profile. To catch the 
true killer, investigators collected blood 
from several hundred male members of 
the community, a process the police 
referred to as a "blooding." 

"Today, with a complete analysis of 
multiple loci," Bieber says, "the proba- 
bility of finding the same profile in two 
unrelated individuals is so remote — in 
the billions, trillions, quadrillions, or 
quintillions — that it has essentially 



become a source identifier " Bieber says 
he prefers to use the term "DNA profil 
ing" rather than "DNA fingerprinting," 
though. "Fingerprinting implies that 
any type of DNA typing is a unique 
identifier," he says, "but there are unusu 
al exceptions, such as identical twins, 
who would have identical nuclear DNA 
profiles. Furthermore, those people who 
have received a bone marrow transplant 
would have different DNA profiles — 
their own constitutional DNA, along 
with the profile of the marrow donor. 
This could create confusion in a forensic 
investigation, depending on the tissue 
source of the biological evidence that 



was 



left at , 



Coming Out in the Wash 

While Jeffreys was using RFLP tech 
niques, Kary Mullis, a young bio- 
chemist working in California, was 
close to another breakthrough. He was 
trying to fix glitches in a prenatal diag- 
nostic test that was not sensitive 



enough to consistently detect the 
genetic mutation that causes sickle-cell 
anemia. To solve the problem, he devel- 
oped a method of amplifying trace 
amounts of DNA into large quantities. 
The technique, called PCR, involves 
repeatedly separating paired DNA 
strands and using each strand as a tern 
plate for a new DNA segment. In the 
late 1980s, two other biochemists in 
California, Henry Ehrlich and Edward 
Blake, realized that PCR could be used 
to investigate crimes. 

The RFLP and PCR systems comple- 
ment one another. Jeffreys's approach 
requires larger amounts of genetic mate- 
rial than Mullis's, but its end product is 
highly discriminatory. Meanwhile, the 
PCR technique can be effective in 
allowing DNA profiling even with trace 
or degraded biological material. 

Bieber recalls his first criminal case, 
one that he says would have benefited 
from PCR amplification. "There was a 
rape in a neighborhood on the South 
Shore of Massachusetts," he says, 



SPRING 2000 • HARVARD MEDICAL ALUMNI BULLETIN 



17 




NA evidence has this unique property where you car 



adding that after the sexual assault, the 
man had made a violent exit, drhing the 
woman's car through her closed garage 
door. "In the initial analysis, there were 
no sperm cells found in the rapist's 
semen obtained from the victim. Yet, the 
age estimate of the attacker was late 
teens to early twenties, so a vasectomy 
didn't make sense. 

"A couple of months later, a rape 
attempt was made in the same neigh- 
borhood. Just as in the first case, the 
man made a violent exit, this time 
crashing through a glass window," 
Bieber says. "All we had was an uncon- 
scious man at Massachusetts General 
Hospital, the 'violent exit' link between 
the two cases, and some incriminating 
statements the suspect later made to 
police investigators." 

At Bieber's suggestion, the prosecu- 
tion obtained a court order to allow him 
to perform a chromosomal analysis of 
the suspect in his laboratory at Brigham 
and Women's Hospital. The test 
revealed that the suspect had a 47, XXY 
karyotype, which invariably leaves 
males with little or no spermatozoa in 
their ejaculate. "While circumstantial, 
this cytogenetic test result was directly 
relevant and therefore probative, con- 
sidering that this defendant was quick- 
ly convicted of all charges," Bieber says. 
"DNA testing at the time wasn't possi- 
ble because there were no sperm in the 
seminal fluid evidence. Today, PCR 
would undoubtedly be used in such 
cases because of its ability to amplify 
DNA in white blood cells and other cel- 
lular debris found in semen." 

By 1988, criminal cases involving 
genetic profiling were being prosecuted 
across the United States. And that year, 
DNA technology was used for the first 
time to exonerate a wrongfully convict- 
ed man, Gary Dotson of Chicago, who 
had been jailed for more than ten years 
on rape charges. 

More recently, the technique was 
used to clear at least one suspect and 



convict another in the murder of Paul 
McLaughlin, a prosecutor in the Massa- 
chusetts Attorney General's Office. 
DNA analysis provided investigators 
with evidence that incriminated Jeffrey 
Bly, now serving life in prison for the 
murder. "What is amazing about this 
case," Bieber says, "is that DNA analysis 
of a hooded sweatshirt found along rail 
tracks near the crime scene revealed 
McLaughlin's blood on the outside of 
the shirt, and Bly's DNA profile on the 
wear area of the collar." 

And last year, Norman Gahn, an 
assistant district attorney in the Mil- 
waukee County Sexual Assault Unit, 
issued one of the first "John Doe war- 
rants," for the arrest of an "unknown 
male" whose DNA profile matches 
DNA evidence collected from three 
rape scenes. "The victims were raped in 
1993," Gahn says. "I issued the warrant 
in September 1999, days before the 
statute of limitations would have 
expired, because once the statute 
expires, there's not much you can do 
when you catch the person." 

Connecting the Dots 

Dramatic outcomes frequently result 
when DNA testing is involved, and its 
exculpatory power has turned many 
lawyers into crusaders for justice. 
"DNA evidence has this unique prop- 
erty where you can go back and look at 
evidence that is 10, 20, 30 years old," 
says Barry Scheck, co-director of the 
pro bono Innocence Project at the 
Benjamin N. Cardozo School of Law in 
New York City, which seeks to use 
DNA testing to exclude those who 
may have been wrongfully convicted 
through circumstantial evidence. "You 
can subsequently speak the truth in a 
trial where the defendant kept claim 
ing his innocence, but was nonetheless 
sentenced to life in prison or death 
row." In addition, Scheck adds, "every 
time you exonerate the innocent, it 




gives you a better chance to catch the 
real guilty party before he goes out 
and commits other crimes. So the pub 
lie safety argument here is critical; it's 
win-win for law enforcement." 

When Scheck founded the Inno- 
cence Project, he says, he only took 
cases in which a DNA test could prove 
innocence. "In they came, inmate after 
inmate, family after family, and exonera- 
tions began to pile up. It spread across 



18 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 



go back and look at evidence that is 10, 20, 30 years old." 




the country to the point where there 
have now been 64 exonerations in the 
United States and six in Canada." 

Assistant U.S. Attorney Christopher 
Asplen, executive director of the Nation- 
al Commission on the Future of DNA 
Evidence, points to another telling sta- 
tistic. "In 20 to 25 percent of cases. DN. \ 
profiling excludes the initial suspect." 

"We're proving that there is a definite 
class of cases where there just so hap 



pens to be biological evidence," Scheck 
says. "But what about all those people 
who go to trial on the same type of eye 
witness identification, jailhouse snitch 
testimony, junk forensic science, prose- 
cutorial misconduct, police miscon 
duct, bad lawyers — what about all 
those people in situations that lead to 
wrongful convictions where there is no 
biological evidence?" DNA testing, he 
says, is highlighting fundamental prob 
lems in the legal system. 

Enthusiasm about the technology 
has given rise to other concerns as well, 
such as the difficulties of implementing 
the technology routinely and properly. 
"Unfortunately, the capacity of the 
DNA labs is terrible in this country," 
Scheck says. "We have a lot of evidence 
from old, unsolved crimes being 
thrown out without doing DNA typ 
ing. We are so backlogged." 

"From the standpoint of applying 
the technology in the criminal justice 
system." Asplen adds, "we have more 
than 180,000 no-suspect rape kits 
across the country that have never been 
DNA tested or entered into any oi the 
convicted-offender databases. Our tech 
nology surpasses what we are currently 
capable of implementing." 

Comicted-offender databases, which 
indi\idual states use to store DNA pro- 
files collected from certain categories of 
convicted rapists and killers, are being 
increasingly used by investigators. The 
FBI Laboratory began employing its 
Combined DNA Index System (CODIS) 
in 1997. The system established common 
standards for forensic testing so that 
states could pool their information. 
Asplen predicts that ever) 7 state will be 
on-line and able to share data with other 
jurisdictions within two to three years. 

As soon as CODIS was activated, it 
was used to place an assailant at a crime 
scene. In August 1989, in Rock County, 
Wisconsin, a 12-year-old girl was riding 
her bicycle when she was abducted by a 
man in his thirties. He raped and beat 



her and left her for dead. Remarkably, 
she survived, but the traumatized girl 
was unable to identify her assailant. 
Then, in December 1997, as databases in 
states across the country were first able 
to compare DNA profiles, a match was 
made almost immediately. A DNA pro- 
file taken from the Wisconsin rape was 
identical to the one obtained from Roy 
Foster, who had been convicted of sev 
eral sexual assaults in Illinois. 

"DNA fingerprinting can lead to 'cold 
matches,' or situations in which DNA 
profiling identifies someone who wasn't 
even a suspect," says Page, the White 
head Task Force member. "This is 
already happening in some states and, 
especially, in Great Britain, where 
they've had a fairly aggressive DNA fin- 
gerprinting program for many years." 

"Many criminals are recidivistic," 
Richer says. "That's the rationale for 
these offender databanks — to link seri- 
al and unsolved cases to known offend 
ers. To date, CODIS has provided 
important investigatory leads in more 
than 600 cases in the United States." 

In the future, adds Page, "it will be 
interesting to see whether DNA finger- 
printing everyone in the population 
becomes the norm." But if a universal sys 
tern were to be installed, he predicts, "one 
can foresee a debate between libertarians 
who will argue that this is a terrible inva- 
sion of privacy, and those who will argue 
that such a measure would improve the 
safety of everyone." He points out that 
such a system already exists. "By far, the 
largest genetic databases in this country 
are the ones involving blood samples that 
every newborn baby in most states 
unknowingly donates for medical, not 
forensic, purposes." 

Page offers historical perspective to 
underscore the significance of policy 
questions about how to bank and access 
DNA information. Back in the 1920s, he 
notes, "a U.S. Supreme Court decision 
authored by Oliver Wendell Holmes III 
essentially opened the door for state- 



SPRING 2000 • HARVARD MEDICA1 A1UMNI BULLETIN 19 




every homicide, we get police to fingerprint the bod) 



mandated sterilization for eugenics pur- 
poses," he says. "All we have to do is look 
at that example to see the role that 
judges and courtrooms will play in 
structuring how the genetics revolution 
is applied to society. It will encompass a 
lot more than DNA fingerprinting." 

By a Hair 

In the meantime, both RFLP and PCR 
techniques, which look at variations in 
either the size of DNA fragments or 
their sequence, have consistently 
improved. In the last three to five years, 
says Bieber, "forensic geneticists 
across the United States and 
Europe have standardized on 
STR typing — profiling DNA by 
examining heritable differences 
known as short tandem repeats. 
These length polymorphisms 
consist of variable numbers of 
adjacent copies of identical four- 
base-pair DNA repeats." 

In addition to STR typing, 
other methods have contributed 
to an increased reliance on DNA 
profiles, Bieber says. PCR can 
now "amplify DNA from trace 
evidence including the saliva left 
on ski masks during robberies, 
the 'wear areas' on the collars of 
shirts, and epithelial cells left on 
a victim's neck by the hands of a 
strangler," he says. 

This type of testing appears to 
have played an exculpatory role 
in one still unsolved case, in which a 
woman was found beaten and dead in a 
wooded area south of Boston. A suspect 
was arrested after bite- mark experts 
examined the patterns left by the perpe 
trator's teeth. This type of examination, 
known as forensic odontology, is a 
growing area, but experts in this case 
could not reach a consensus on the 
source. Ultimately, profiling of DNA 
swabbed from the wounds did not 
match the suspect's DNA profile. 



Investigators are benefiting from 
another scientific advance as well: the 
typing of mitochondrial DNA, which is 
"found in the non-nuclear component of 
cells," Bieber says. "It has tremendous 
utility for typing hair shafts, bone, and 
fingernails that don't contain adequate 
nuclear DNA. Evidence from mitochon- 
drial DNA sequencing has now been 
used in three homicide cases in the 
United States, and all the convictions 
have been upheld on appeal." 

Mitochondrial DNA evidence was 
introduced for the first time in a U.S. 
courtroom in Tennessee in 1996. Before 




the testing was performed, only circum- 
stantial evidence pointed to 27- year- old 
Paul Ware as the suspect in the rape 
and murder of a four year old girl. The 
child's blood was not found on the sus- 
pect, and his semen was not found on 
her body. Yet, the mitochondrial DNA 
found in a single strand of red hair col- 
lected from the girl during her autop 
sy — and in several red hairs collected 
from the crime scene — matched the 
defendant's DNA profile. 



The technology, however, is a dou- 
ble-edged sword, says Richard Lewon- 
tin, a professor at Harvard University's 
Museum of Comparative Zoology, who 
has testified in court about DNA evi- 
dence. "It gives the state a powerful 
scientific legitimacy even if the lab 
work was sloppy," he says. "When you 
have the suspect's blood in a large tube, 
and a smidgen of blood from the crime 
scene, if you're not careful, you can 
contaminate the crime scene with the 
suspect's blood." 

That's the real risk, Page says. "People 
take great comfort in talking about 
DNA matches as a statistical ques- 
tion, but the problem is that the 
one thing you can't describe ade- 
quately through statistics is the 
real danger — bookkeeping errors 
or contamination." 

"The technology makes convic- 
tions all the more credible because 
they've been done in the name of 
science," Lewontin says, noting 
that incorrect matches also can be 
made because technicians simply 
"don't look at enough genetic 
markers." There is an upside, he 
adds. "The technology can actual 
ly be used to exculpate people, but 
it takes time and money." 

It's in the Blood 



In addition to looking to suspects' 
DNA for answers, investigators 
sometimes find surprising infor- 
mation in the genetic makeup of some 
of society's youngest victims. 

"Physicians and other caregivers are 
duty-bound to report suspicious signs 
of child abuse or neglect," Bieber says. 
But, he adds, "collectively, we need to be 
more aware of genetic conditions that 
can masquerade as trauma or abuse. 
Examples include heritable chon 
drodysplasias, which can present with 
bone fractures and may be mistaken for 
traumatic injuries. 



20 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 



If there still is no identification, we look at dental charts. 



55 



A case in St. Louis highlights anoth- 
er example of genetic conditions mim 
icking child abuse. Methylmalonic- 
acidemia is a rare autosomal recessive 
disorder that can be misinterpreted as 
ethylene glycol poisoning. In this case, a 
woman was actually convicted of mur 
der when her first child died and two 
laboratories incorrectly reported find 
ing ethylene glycol — a component of 
automotive antifreeze — in the child's 
serum and urine. 

"Medical geneticists watching the 
news recognized the features of methyl 
malonicacidemia," Bieber says. "And 
when the woman's second child was 
born in prison, that baby presented 
with the same symptom complex. 
Under court order, appropriate testing 
revealed that both infants suffered from 
the same genetic condition. Her convic 
tion was eventually vacated, and the 
second child was treated." 

Yet what if scientists could identify 
something more sinister in the genes — 
variants that predispose individuals to 
violent, potentially criminal behavior? 
To what extent should that information 
be admissible in court? The question, 
says Page, is not merely hypothetical. 

"A monoamine oxidase deficiency 
was discovered in a family in Holland 
that was unambiguously correlated 
with violent behavior," he explains. 
"Out of that revelation have come sever- 
al attempts to base criminal defenses on 
the possibility that the person charged 
carries a similar gene. In criminal pro 
ceedings, we will see how notions of 
culpability change as the debate over 
genes and behavior rolls forward." 

Tales from the Crypt 

Despite advances in DNA testing and 
its applications, medical examiners 
use many of the same techniques today 
as they did decades ago, says Leonard 
Atkins, associate professor of patholo 
gy at HMS. 



"I've worked in this field for 43 years 
and have performed more than 4,000 
autopsies," Atkins says. "To identify the 
body, I do pretty much the same things 
today that I did back in 1957. I look tor 
the usual statistics, such as height and 
w eight. On every homicide, we get 
police to fingerprint the bod}'. If there 
still is no identification, we look at den 
tal charts." 

To determine the cause of the victim's 
death, and to glean any other relevant 
information, Atkins looks for specific 
clues while performing autopsies. 
Details — such as the direction a bullet 
entered the body, the pattern imprinted 



on a blunt injury wound, the nature of 
chemical burns around the mouth, fin- 
gernail marks or grooves on the neck, or 
the size and appearance of a stab 
wound — can become crucial points in 
court. "Murder cases are different from 
those encountered in a hospital practice, 
where the person has been fully worked 
up," Atkins says. "Sometimes all we have 
is a body, with no other information." 

He recalls one case in which his 
sleuthing helped solve a murder. In 1971, 
a badly decomposed human torso with 
a hatchet embedded in its chest was 
discovered in an inlet of Boston Harbor. 
Atkins determined that a gunshot 




SPRING 2000 • HARVARD MEDICA1 A1UMNI BULLETIN 



21 




ou can trace evidence at a scene with just the saliva 



wound was the cause of death. But 
identifying the victim would prove to 
be much more difficult. Because the vic- 
tim's head had been severed, Atkins 
couldn't rely on dental records, and 
because the hands were missing, he 
couldn't rely on fingerprints. With little 
else to go on, he had x-ray films made of 
the torso. 

At the time the body was found, the 
Boston Police Department was investi- 
gating the disappearance of John James 
Rooney, a white male within the age 
span Atkins had attributed to the torso. 
Atkins knew that without Rooney's 
body, it would be difficult for prosecu- 
tors to try the case. 

"I thought the victim might have 
been seen at Boston City Hospital since 
he was from Dorchester," Atkins 
recalls. "Sure enough, he had been 



treated there twice in the last six 
months for back and shoulder prob- 
lems." Atkins requested that the ante- 
mortem and postmortem films of the 
chest and spine be compared, and a 
radiologist determined that the victim 
was indeed Rooney. "Each individual 
has a pattern to his or her bones that is 
unique," Atkins explains. 

The defendants were convicted, 
largely on the basis of the medical evi- 
dence. Atkins adds that the case was the 
first criminal trial in which a corpse was 
identified on the basis of normal bone 
patterns seen on x-ray films. 

Although he "does the same amount 
of work" that he has always done, 
Atkins notes that advances in DNA 
testing mean that "we have more preci- 
sion in terms of identifying someone 
who was at a particular place at a cer- 




tain time — it overwhelms every other 
advance. You can trace evidence at a 
scene with just the saliva on a cigarette." 
In late January, in fact, a former 
Boston man was sentenced to life in 
prison for raping and murdering a 19- 
year-old college student whom he met 
on the subway. The crucial evidence? 
Cigarettes the suspect had left behind 
after police questioned him. The saliva 
left on the butts was tested for DXA. 
evidence that was ultimately key to his 
conviction. At the time of the interro- 
gation, the suspect, Lee Perkins, was 
serving a prison sentence on a prior 
rape conviction. 

Cracking Cases 

In addition to DNA profiling, advances 
in nuclear medicine and toxicology 
testing are helping to solve crimes. "In 
the 1950s," says Charles Petty '50, pro- 
fessor of forensic sciences and pathol- 
ogy at the University of Texas South 
western Medical Center at Dallas, 
"there wasn't much more in forensic 
toxicology than test-tube science. We 
didn't have delicate, sophisticated 
instruments. We didn't have nuclear 
magnetic resonance analyses to detect 
heavy metals such as arsenic, or high 
pressure liquid chromatography to 
test for foreign substances." 

One case in particular, he says, high 
lights how much has changed in the last 
50 years. In 1956, Petty took a short 
term job covering for a pathologist in 
smalltown Louisiana. While he was 
there, a physician stopped by to relate a 
perplexing case — his patient had expe- 
rienced sudden onset of diarrhea and 
vomiting and felt peculiar. 

"I suspected arsenic poisoning," 
Petty says, "and I suggested we test his 
urine. But there were no forensic or 
crime labs in town, so I did an old-fash- 
ioned test. I took a penny, cleaned it 
with nitric acid to make it shiny, 
dropped it in the patient's urine, and 



22 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 



on a cigarette. 



•>i 



brought it to a boil. The penny turned 
black from the arsenic deposit. We 
found out that the man, who later died, 
was suicidal and had eaten the arsenic 
deliberately. 

"But that was arsenic poisoning then. 
In this day and age, we can make that 
diagnosis in all sorts of ways. Now we 
can detect minute quantities of drugs in 
a person's system, and we can get an 
idea of how long it has been since the 
person ingested the drugs." 

In the Field 



The future will hold even more 
advances, Bieber says. In four to six 
years, he estimates, "microchip array 
systems, which allow many genetic- 
tests to be done in parallel on a small 
surface, may one day enable limited 
DNA testing in the field. We won't need 
to send the samples to the lab; I predict 
that we'll be able to perform some ini- 
tial screening using portable imple 
mentation." 

"The ability to test at the scene is 
coming along so rapidly," Petty 7 says. "It 
will have a tremendous impact." Such 
testing would have implications far 
beyond crime solving — it could be 
employed, for example, to rapidly iden 
tify victims of mass disasters, plane 
crashes, or war. The military is already 
collecting DNA on its soldiers as mod 
ern day dog tags. 

"We need to improve the laboratory 
infrastructure so that police can really 
use DNA e\idence as an investigative 
tool, rather than arresting suspects 
based on other evidence, and just using 
the DNA as a means to prove their guilt 
in court," Asplen says. "That's the real 
future of the technology — being able to 
do more with less." 

Weighing Evidence 

Much of what forensics attempts to do 
is identify pieces of evidence, Bieber 




says. "What is it? Where is it? Where 
did it come from?" 

As investigators struggle with these 
types of questions, scientific advances 
will continue to add to their arsenal. In 
the meantime, expert witnesses will 
do their best to help judges and juries 
weigh the relative importance of each 
piece of medical evidence. It's a task 
that can be both technically and emo- 
tionally demanding, and sometimes 
frustrating. 

Page decided never to testify again 
after serving as an expert witness in a 
murder trial in the late 1980s. "It's as if 
you're a horse with blinders and a 
very tight rein," he says. "I felt very 
much like a pawn on the witness 
stand. Expert witnesses are led 
phrase by phrase by attorneys. 
They're rarely given an opportunity to 
expound on what they believe to be 
the most relevant aspects of a particu 
lar question." The defendant in that 
case was exonerated. 



When Bieber testifies, he feels "an 
overwhelming sense of responsibility to 

be a fair and impartial expert witness. 
You know jurors may be hanging onto 
your every word. Every single case I've 
worked on is full of drama, because lives 
have been lost." Bieber compares court 
room testimony to teaching a small 
seminar. "The role of the expert witness 
is to remain an impartial educator to a 
class of 12," he says. "And attorneys have 
related to me that of all the testimony 
jurors hear, they are particularly inter- 
ested in DNA evidence." 

The significance of recent advances in 
forensic medicine is certainly not lost on 
the families of \ictims like Mary Theresa 
Burhoe. "I thought I never would see the 
day," the girl's stepfather, Richard Var- 
denski, told the Boston Globe when a sus- 
pect was arrested nearly 20 years alter 
the crime. "It feels great." ■ 

Phyllis L Fagell is associate editor oj the 
Harvard Medical Alumni Bulletin. 



SPRING 2000 • HARVARD MEDICAL ALUMNI BULLETIN 



23 




MEDICAL 
DETECTIVES 



24 




A physician applies his knowledge of the dead to help the living 



FROM ALASKA TO THE CAYMAN ISLANDS, JOHN MARRACCINI 

78 has enlightened courts, legislatures, and law 
enforcement agencies with his knowledge of topics 
ranging from gunshot injuries to poisonings. The 
areas of expertise detailed in his curriculum vitae, in 
fact, provide harrowing testimony to the fragility of 
the human body and psyche: blood spatter caused by 
gunshot wounds; sharp- edged weapon injury pat- 
tern and interpretation; electrocution injuries; drug 
intoxication and human behavior. The list spans two 
pages, documenting the various ways in which 
human beings can meet with — and inflict — death. 

by Beverly Ballaro 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 



^ 



f 








Once Marraccini became a father, he found it increasingly 
autopsy seems like your own baby, and you vicariously feel 




k-puty Chief Medical Examiner John Marraccini demonstrates on prosecutor John Movie how broom 
andle could have caused neck injury found on Mario Abraham's body. 



Judge: Jninjito'e death V»* : 



n 



What drew Marrac- 
cini to the field of foren- 
sic pathology, however, 
was not a preoccupation 
with the macabre, but a 
desire to help families 
and society by pursuing 
with vigor and intelligence the cause of 
death. In his 14 years of work in the 
medical examiner's office of Palm Beach 
County, Florida, where he was eventu- 
ally appointed chief medical examiner, 
Marraccini brought numerous mysteri- 
ous cases to closure. 

"Yet the pain of loss remains for the 
families and survivors," Marraccini 
says. "Helping to bring a murderer to 
justice provides little solace — the 
touch and voice of a husband or father 
cannot be replaced. The void created by 
the death of a child is never filled by the 
passage of time. Guilt and sorrow are 
the legacy, and for all we do to docu 
ment death, medical examiners cannot 
palliate these human aches." 

Forensic science flourished at HMS 
in the forties and fifties, but Harvard's 
interest gradually waned, perhaps, 
Marraccini speculates, because the 
field was widely perceived as not being 



SWEPT AWAY: 

During a public inquest, 

Marraccini demonstrates 

how a broom handle 

could have inflicted a 

lethal neck injury on 

the murder victim. 



conducive to cutting- 
edge technology. After all, 
the basic tools of his trade 
have been around for 
quite some time; the use 
of the autopsy goes back 
at least 600 years, and 
microscopic slide examinations around 
120 years. Although DNA analysis is a 
powerful and thoroughly modern tool, 
it tends to be conducted not by medical 
examiners' offices, but at associated 
crime laboratories. 

For these reasons, Marraccini says, 
some continue to \iew forensics as a 
backward science belonging to the 
descriptive phase of medicine. Yet he 
and his colleagues have continually 
refined their profession, thanks to a 
judicial environment that now routine- 
ly subjects their opinions to tough 
scrutiny. Marraccini welcomes this 
change, which has made forensic sci 
ence a more rigorous discipline. "When 
you can anticipate and answer every 
conceivable question — and enjoy the 
process — you know you've come into 
your own as an expert," he says. 

Over the years, Marraccini has 
delved into many fascinating cases of 



sudden death, including those caused 
by virtually every variation of natural 
disease: obscure vascular malforma- 
tions, myocardial disease, bands of 
Ladd, Addisonian crises, allergic phe- 
nomena, strange septicemia, and the 
earliest cases of AIDS. He has also ana- 
lyzed hundreds of accidental deaths, 
acquiring along the way a profound 
understanding of which vulnerable 
points of the human body characteris- 
tically give way to shearing and crush- 
ing forces. 

Yet some of Marraccini's most strik- 
ing insights have come not in the area of 
anatomy but in the realm of human 
character, which, he wryly notes, "has 
not changed much, and yet the vices 
come and go." He has autopsied more 
than one patient who died in a plastic 
surgery misadventure in the never-end- 
ing quest for beauty, and he has wit- 
nessed overdoses shift from heroin to 
cocaine to ecstasy to rohypnol and 
back again. He has seen intoxications 
decline, drive-by shooters replace 
cocaine cowboys, and the homicide 
body count drop to half of what it was 
in the early eighties. 

Out of the Ashes 



Throughout the parade 
of mayhem, Marraccini 
has held fast to the pre- 
ventive knowledge and 
ethical advances that 
have emerged from his 
work. When airbags 
came into vogue and began to create 
their own distinctive injuries, for exam- 
ple, it fell to Marraccini and others in 
his field to bring to light the unforeseen 
hazards inadvertently built into this 
new safety measure. Establishing that 
airbag injuries were claiming the lives 
of children because car designers had 
not taken passenger stature into 
account led to what Marraccini 
describes as a "transition in under- 



26 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 



difficult to autopsy children. "Every victim you 

the devastation of the surviving parents more and more.'* 



standing" that has brought about bene 
ficial change. 

The evolution in police restraint 
methods represents another such tran 
sition. When, in the early eighties, 
Marraccini first began investigating 
cases of suspects who had died in 
police custody, some of these deaths 
were ruled accidents, others homi 
cides. In judo, Marraccini knew, a com- 
petitor will immobilize his opponent's 
body before applying careful 
pressure to the carotid artery, 
causing his opponent to pass out. 
The carotid sleeper hold — rea- 
sonably safe when practiced in a 
controlled, sporting environ 
ment — can turn lethal, however, 
when applied to a squirming, 
resisting suspect, as Marraccini 
and others helped to establish. 

Other mysteries remain in the 
investigative phase; in 1985, Mar- 
raccini worked on the case of a 
child who died suddenly in her 
sleep, 12 years after she had nar- 
rowly escaped death from sudden 
infant death syndrome (SIDS). 
The child's tissues are now being 
reexamined, using molecular 
probes, to determine if there 
might be a kind of SIDS death 
related to prolonged QT interval 
that medicine has yet to identify. 

Marraccini — whose recreation- 
al activities include pistol and 
rifle shooting, archery, the martial 
arts, and tomahawk and knife- 
throwing — has, more than once, relied 
on knowledge acquired outside of his 
HMS education and the medical 
examiner's office to solve a mystery. In 
fact, he says, what makes the medical 
examiner's job intellectually com- 
pelling is having to draw upon a detec - 
five's reservoir of information, experi 
ence, and intuition. 

"Sometimes" he says, "the missing 
piece of the puzzle can even be related to 
something that you learned when you 



were five years old. I once reviewed a 
case, for example, in which the victim 
displayed unusual head wounds. No one 
could figure out what could possihlv 
have produced such injuries. When I 
looked at them, I flashed back to an early 
childhood memory of the damage inflict- 
ed when one boy hit another with a 
piece of coral rock. Sure enough, such a 
rock was eventually suspected to be the 
murder weapon in this case ." 




DEAD GIVEAWAY: Marraccini examines a skull 
with three bullet holes. The skull was found by 
a construction worker in Boca Raton, Florida. 



Knowledge of the local flora and 
fauna has frequently helped Marraccini, 
a Florida native, in his job. He once 
helped evaluate a case by recognizing 
some baffling injuries on the victim's 
arm as having been inflicted by the play- 
ful gnawings of a pet macaw. Familiarity 
with the current flows of the local rivers 
has helped him know where to hunt for 
evidence dumped in the water. Know- 
ing the kinds of artifacts left by the crea- 
tures who inhabit the area has also 



played a gruesomely practical role: alli- 
gators and snapping turtles produce 
distinctive marks on corpses. And, Mar- 
raccini notes, red ants create a peculiar 
pattern resembling gunshot wound tat- 
tooing, which might mislead someone 
not familiar with the ants' habit of 
c he wing on blood spots from high 
velocity spatter around bullet wounds. 
Deducing the truth from such clues 
provided the kind of intellectual and 
scientific challenges that led to 
Marraccini's original fascination 
with his field. Once he became a 
father, though, he found it 
increasingly difficult to autopsy 
children. "You begin to wonder 
what intervention might have 
been attempted to prevent a teen 
suicide," he says. "Every victim 
you autopsy seems like your own 
baby, and you vicariously feel the 
devastation of the surviving par 
ents more and more." For this 
reason and others, Marraccini 
found himself, after all those 
years in the medical examiner's 
office, wishing he could make 
more of a difference on a person- 
to-person level. He now puts in 
forty hours a week in family 
practice and ten in lorensic work. 
Initially, the career transition 
proved challenging. "Working 
with the dead for so long made 
me a bit paranoid when taking 
patient histories," he says. "At 
first, I expected every patient to 
die an untimely death." But his long 
and intimate knowledge of death and 
disease, Marraccini has realized, lends 
him a unique authority when explain- 
ing to patients why they need to adopt 
healthier lifestyles. "It's not every 
physician," he says, "who can apply 
lessons learned from 4,000 autopsies 
to the land of the living." ■ 

Beverly Ballaw is assistant editor of the 
Harvard Medical Alumni Bulletin. 



SPRING 2000 • HARVARD MEDICAL ALUMNI BULLETIN 



27 




icrobe 



microDe 



There once was a cow from the west 

who thought Dr. Brooks was a pest; 

"He says I'm diseased," 

said the bovine, displeased, 

"and I'm causing the trots in my guests." 

NOT MANY PHYSICIANS COULD INSPIRE A PATIENT TO SCRIBBLE A 

paean such as this, but John Brooks '94 has always marched to a 
different beat. As a boy of 13, his fascination with the great med- 
ical detective narrative Microbe Hunters sparked dreams of a 
career in medicine and foreshadowed his current job as an Epi- 
demic Intelligence Service officer assigned to the Foodborne 
and Diarrheal Diseases Branch of the Centers for Disease Con- 
trol and Prevention. 

Brooks followed a roundabout path to HMS, majoring in 
German and earth science as an undergraduate and deferring 
medical school for several years in order to travel the world. At 
HMS, he quickly developed a passion for the study of infec- 
tious disease, intrigued by the formidable breadth of knowl- 
edge it demands. 

"Medical epidemiologists must understand everything," he 
says. "From caring for individual patients to puzzling out the 



by Beverly Ballaro 



28 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 











* 

















' 



Jki'AS: 



Casting such a wide surveillance net inevitably yields its share 



origins of diseases that can ravage 
entire communities, they must have 
both a capacity for minute detail and 
a broad perspective. All medicine is 
voyeuristic by nature, but epidemiolo- 
gy is especially so." 

Constructing an explanation from a 
mountain of details, Brooks concedes, 
can seem like hunting for proverbial 
needles hidden in haystacks. Yet while 
some may view epidemiology as an 
imprecise science, Brooks says he 
thrives on the challenge of tracking 
down the source of an outbreak, liken- 
ing it to "solving a 3-D puzzle in which 
time and geography are two of the 
dimensions." 



Und 



ercover 



Work 



Chasing down outbreaks requires 
Brooks to exercise skill not just in 
microbiology, but also in psychology 
and cultural diplomacy. His work on a 
World Health Organization-spon- 
sored polio eradication project in Fiji, 
for example, took him to remote 
islands where he discovered that 
wearing a sulu (a traditional skirt-like 
garment) earned him credibility, and 
partaking of kava (a popularly con- 
sumed sedative -like substance) made 
local community members receptive 
to his medical initiatives. 

These lessons have stood Brooks in 
good stead. Although the Public Health 
Service started out as a branch of the 
Navy and, consequently, Brooks dutiful- 
ly dons his Commissioned Corps uni- 
form every Wednesday, he never wears 
it on investigations. "Just think about 
the intimidation factor," he points out, 
recalling an outbreak caused by conta- 
minated cheese that affected a popula- 
tion of illegal aliens. 

Putting wary patients at ease is 
essential to the success of Brooks's 
work. In what he describes as his 
"most adorable outbreak," he was 
called upon to investigate a salmonella 
strain that sickened kindergartners 



30 HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 



touring a dairy farm. Brooks traced the 
problem to the tradition of allowing 
children to sample unpasteurized 
milk. To solve the mystery, though, he 
found himself conducting a scientific 
investigation for whose rigors HMS 
had not prepared him. 

"Can you imagine what it's like to 
interview 100 five-year-olds?" he recalls 
with fond exasperation. "They're just at 
the age when they're eager to tell stories, 
but they're not always the most reliable 
of narrators." The children enthusiasti- 
cally reported to Brooks how they had 
drunk "milk from the big, brown cow," 
but then also had "petted giraffes" and 
"built snowmen." 

Stranger than Fiction 

Like any good detective, Brooks knows 
that the solutions to mysteries some- 
times defy plausibility. He cites the ear- 
liest domestic cases of HIV infection — 
in which young and seemingly healthy 
gay men were being afflicted by a rare 
form of pneumonia — as an example of 
the outlandish emerging as reality. For 
this reason, he and his colleagues at the 
CDC treat as potential early warnings 
all the tips and inquiries that regularly 
pour into their offices from state health 
departments, governmental agencies, 
and the occasional private citizen. 

Casting such a wide surveillance net 
inevitably yields its share of surreal 
moments. "As a custodian of the public 
health, you have to respond to every 
inquiry," Brooks explains, which 
accounts for why the phone duty log on 
his desk documents queries such as the 
one from the woman concerned about 
the safety of her daughter's swimming 
in the family pool with her pet goose; 
the man claiming that an outbreak of 
listeriosis was due to UFOs adulterat- 
ing the goats in his back yard; the 
inmate worried about contracting viral 
hepatitis from drinking a cup of coffee 
into which he'd seen a fellow inmate 
urinate ("If you saw this happen, then 



why did you drink it?!"); and the teen 
wanting to know whether the direc- 
tions he found on the Internet for man- 
ufacturing botulinum toxin would 
actually work ("No!"). 

Public Health Affairs to Remember 

Brooks's most memorable outbreak 
investigations have rounded up their 
suspects through a combination of 
sophisticated technologies, case con- 
trol studies, and a detective's intu- 
ition. Last spring, a string of salmonel- 
la cases afflicting young women from 
the lightly populated western part of 
Colorado had investigators stumped. 
Epidemiology, like police work, has its 
own victim profiles; Brooks knew 
from his branch's long experience 
with foodborne outbreaks that young 
women are typically infected by pro- 
duce in these kinds of outbreaks, yet 
the usual suspects, such as tomatoes, 
were not yielding any clues. 

Interviews with the women seemed 
to implicate first an unusual fruit 
soda, then a dairy- based chocolate fill 
ing, but, again, these leads went 
nowhere. In the end, a case control 
study revealed a shipment of sprouts 
as the culprit. An exhaustive check of 
farm, processing plant, and supermar- 
ket records traced the outbreak to a 
single lot of clover seed. Although the 
seeds had been soaked in chlorine (the 
recommended method for decontami- 
nating sprout seed), this measure had 
reduced — but not eliminated — the 
risk of contamination. 

That same year. Brooks was called in 
to investigate an E. coli diarrheal out- 
break in a Texas cheerleading camp. 
"Interviewing 650 teenage girls about 
what they'd eaten and how much 
they'd vomited was quite an experi- 
ence," he muses. Although microbiolog- 
ical proof was not available, the statisti- 
cal analysis left little room for reason- 
able doubt. Brooks identified a major 
mode of transmission as the girls' habit 



of surreal moments. 



of dipping their water bottles in large, 
communal ice buckets. 

Guilty by Suspicion 

Frustratingly, some cases resist crack- 
ing, despite the most rigorous inves 
tigative efforts. In one instance, a major 
outbreak of listeriosis was traced back 
to contaminated hot dogs. Most of the 
bacterial isolates collected from sick 
patients during this outbreak shared 
an identical DNA fingerprint. From 
within this large group of patients, 
however. Brooks and his colleagues 
identified a small cluster of Listeria 
isolates with a different DNA finger- 
print. An unusual confluence of com- 
mon denominators suggested a link 
between the people in this subgroup: 
they had generally nor consumed hot 
dogs; they inhabited the same geo- 
graphical area; they had Eastern Euro- 
pean last names; and, most intriguingly 
of all, they all shopped at various Polish 
specialty stores. Although Brooks and 
his state health department colleagues 
just knew that the connection had to 
reside in those shops, they were never 
able to nail the culprit. 

The nature of his work often places 
Brooks in a tough position because he 
has learned that, although "some oper- 
ations are just plain dirty and deserve 
to be shut down, more often than not, 
it's well-intentioned people in good 
companies whose production hygiene 
meets the minimum standard yet, 
somehow, a pathogen has managed to 
wreak havoc. The owners are usually 
shocked that their product could be 
responsible for making people sick." 

The consequences of an investiga- 
tion can be devastating, Brooks says. 
One apple juice company was nearly 
bankrupted as a result of the litigation 
and negative publicity that followed an 
outbreak. Brooks worries about when 
to make information public, fully 
aware that he holds the power to dis- 
rupt jobs, reputations, and even local 




economies. Nonetheless, he is commit 
ted to protecting the public health, 
regardless of the economic impact. 

Risks and Rewards 



Brooks's job yields great rewards but 
also requires sacrifices. Being on 
round-the-clock call to travel to any 
global hot spot with minimal notice 
complicates his personal relation 
ships. Frequent overseas travel also 
precludes his being able to work in 
clinical care. He misses getting to 
know patients; while he is proud of 
taking many little steps to help large 
numbers of people, he speaks wist 
fully about the joys of exercising a 



profound, visible impact on individ- 
ual lives. 

Nonetheless, Brooks remains pas- 
sionate about his work and philosoph 
ical about the intangible nature of his 
success. Last year, for example, he man 
aged a diarrhea surveillance system in 
Africa that picked up a cholera epidem- 
ic early enough to be nipped in the bud. 
"The irony of this work is that when 
you do your job well, you can't prove 
it," he says. "We'll never know how 
many people would have died, yet the 
knowledge that many lives were saved 
is tremendously satisfying." ■ 

Beverly Ballaro is assistant editor of the 
Harvard Medical Alumni Bulletin. 



SPRING 2000 • HARVARD MEDICAL ALUMNI BULLETIN 



31 



Although about half of all autopsied deaths are due to 



natural disease processes, sometimes of diseases unsus 



ected, it is a myth born of Hollywood and 




always definitively identify the cause of death. In a good 






In about 






for the examiner to reach any firm conclusion 




S A YOUNG MAN, CHARLES PETTY '50 ABSORBED TWO VALU- 

able, and not unrelated, lessons: human nature is 
capable of truly insidious deeds; and, the discerning 
eye can see that things are not always as they appear. 
As an organic chemistry student, he had been 
intrigued by a case his professor described of a 
woman who had died suddenly and violently By 
dumping the contents of the woman's sugar bowl 
onto a clean piece of paper, and watching them sepa- 
rate into two components — sugar and arsenic triox- 
ide — the suspicious professor was able to prove that 
the woman had been poisoned. 

At HMS, Petty's fascination with medical detec 
tive work was sparked anew when he spotted an 
unusual display in the Warren Anatomical Museum: 
an old, cast-iron, potbellied stove that, remarkably, 
had been partially melted down. He learned that 
George Burgess McGrath, venerable professor of 
legal medicine at HMS, had used the stove as proof 





by Beverly Ballaro 



Even the seemingly straightforward criminal cases 



that a man had detonated a thermite 
bomb to ignite a conflagration that he 
vainly hoped would cover up his 
wife's murder. 

Petty entered the field of forensic 
pathology because he realized that 
not all medicine is about directly 
treating patients, and that the appli- 
cation of scientific and medical 
knowledge can serve other, equally 
important healing purposes. "When a 
mother discovers her four-month-old 
dead in his crib, she wants to know 
why her child died," he says. "I can 
relieve her of some of her guilt by 
explaining that the child did not die 
'on her watch 1 — that his death was 
not her fault. It's almost like provid- 
ing psychotherapy. I also act as a pro- 
tector of the public health by uncov- 
ering hazards. Although it's misun- 
derstood by many, this field is really 
about helping people." 

Readings from the Book of the Dead 

Jk mong his many distinguished 
/% professional roles, Petty is a 
% professor of forensic sci- 
^ ences and pathology at the 
_Z_ JL_ University of Texas South- 
western Medical Center at Dallas. He 
has also worked as chief medical exam- 
iner for Dallas County, where he ran the 
crime laboratory. And he has served as 
director of the Dallas County Rape Cri- 
sis and Child Sexual Abuse Center. 

Although Petty has worked many 
criminal cases in his career, he does not 
dwell on the evils he has witnessed, but 
focuses instead on the problems to be 
solved. "Doing an autopsy is interesting," 
he says, "because dead men really do tell 
tales." In personally conducting more 
than 13,500 autopsies and supervising 
another 40,000 to 50,000 throughout his 
career, Petty has helped to unravel many 
a mysterious tale. 

Sometimes, solving the puzzle 
requires detective work of the old-fash- 
ioned variety. Petty once investigated the 
case of a seemingly robust and healthy 
man in his late twenties who was found 



dead in his well appointed apartment, 
with no evidence of foul play. A routine 
check of local hospital records brought 
to light that the young man had, in fact, 
undergone electrocardiograms that had 
identified prolonged QT interval, a con- 
dition that makes its carriers prone to 
sudden and unexpected death. 

Occasionally, the solution to a case 
turns up through serendipity. A physi- 
cian once sent Petty the body of a 
woman for examination. The physician 
also passed along an uncannily familiar 
description of the symptoms the 
woman had exhibited right before she 
died. Petty just happened, at that time, 
to be engaged by the government in 
research on developing a human anti- 
botulinum serum. An analysis of the 
woman's bowel contents confirmed 
Petty's immediate suspicion that she 
had died of accidental poisoning, due in 
this case, it turned out, to tainted 
canned tomatoes. 

Petty has also handled cases whose 
results defied all plausible expecta- 
tions. When an associate asked him to 
conduct an autopsy on his wife, who 
had died mysteriously, Petty agreed to 
help. When he phoned his colleague to 
inform him that his wife had died of a 
brain metastasis from a thyroid carci- 
noma, the man was stunned into 
silence. His wife had, indeed, under- 
gone surgery for the removal of her can- 
cerous thyroid — 25 years earlier. 

To Catch a Killer 



The criminal cases Petty has 
investigated provide sad evi- 
dence of human psychologi- 
cal, rather than physiologi- 
cal, processes gone patho- 
logically awry. Some years ago, he was 
brought in to solve the mystery of what 
had killed a young woman found dead in 
the bedroom of her home. The victim 
was apparently unscathed, and there 
was no evidence of a robbery or any type 
of intrusion. 

Petty mulled the layout of the 
house — which featured a garage on 



the north side, bedrooms on the south 
side, and a swimming pool in the 
yard — and concocted a chilling sce- 
nario: the woman's husband had taken 
a hose ordinarily used to clean the 
pool, and snaked it from a car exhaust 
pipe in the garage, around the side of 
the house, and through the bedroom 
window in order to suffocate his wife 
with a lethal dose of carbon monoxide. 
Traces of auto exhaust gas found on 
the hose and in the victim's blood bore 
out Petty's theory. As fate would have 
it, a different distribution of carbon 
monoxide in the air currents in the 
house spared the life of the infant who 
was also sleeping in the bedroom at 
the time of his mother's murder. 

Even the seemingly straightforward 
criminal cases yield the occasional odd 
twist, Petty says, recalling one instance 
in which a tall, obese woman was 
found, presumably beaten to death, in 
her own home. Her body was discov- 
ered lying in a peculiar position, 
sprawled on the floor but with one leg 
propped up on the bed. Petty quickly 
identified a poker with a missing hook 
as the suspected murder weapon; the 
screw threads on the poker made a dis- 
tinctive and precise match with the 
injury patterns on the woman's body. 

Petty was reluctant to rule that the 
beating was the cause of death, howev- 
er, because, the injuries, as horrible as 
they were, didn't seem to be so severe 
that they could have been fatal. Petty 
and his colleagues spent considerable 
time reviewing the crime scene photos 
side by side with the autopsy photos 
before they came to an eerie realiza- 
tion. The woman had, in fact, not died 
from the beating itself but from 
asphyxia — the weight of her own 
enormously heavy leg pressing against 
her abdomen had stopped her breath 
ing — and the cause of death was offi- 
cially ruled strangulation by beating. 

"The key to getting to the bottom of 
an unexplained death, whether natur- 
al or unnatural," says Petty, "is making a 
commitment to going all the way in con- 
ducting an examination. You can't be 



34 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 



yield the occasional odd twist, 



denied the opportunity to examine the 
entire body and be expected to figure 
out the truth of what took place." When 
he lectures his students. Petty frequent- 
ly reminds them of one cardinal rule: 
"When you look at a corpse, that body 
can and will tell you its story, if you are 
prepared to look properly." 

Petty himself learned this lesson 
early and the hard way; as a young 
medical examiner in Baltimore, he was 
hung out to dry by a defense attorney 
during a blistering 30 minute interro- 
gation on the implications of his fail- 
ure to examine the head of a victim. 
"Failure to examine the whole body is 
the classic and leading mistake in 
forensic medicine," he says. 

No matter how thorough the 
autopsy, however, the truth behind 
mysterious deaths can still occasion 
ally prove elusive. Although about 
half of all autopsied deaths are due to 
natural disease processes, sometimes 
of diseases unsuspected or neglected, 
it is a myth horn of Hollywood and 
television dramas, Petty says, that 
medical science can always definitive- 
ly identify the cause of death. In a 
good medical examiner's office, he 
estimates, autopsies fail to determine 
a cause in roughly 5 to 7 percent of all 
cases. In about a third of these cases, 
the degree of decomposition of the 
body is too advanced for the examiner 
to reach any firm conclusion. Cases of 
SIDS — sudden infant death syn- 
drome — account for another third 
("we're just too stupid to figure out 
why these infants die," Petty sighs). 
The remainder of unexplained deaths 
generally occur among women in the 
adolescent through menopausal phas- 
es of life for a variety of causes that 
defy medicine's understanding. 

The Good, the Bad, and the Ugly 



F 



orensic pathology, Petty 
warns, comes with its own 
unique set of challenges, and 
any young doctor contem- 
plating a career in the field 



1 



should be aware of several 
points. "One key difference 
between regular medicine 
and forensic medicine," Petty 
says, "is that medical exam 
iners are responsible to the 
governing authority in the 
jurisdiction in which they 
work. A lot of doctors don't 
particularly like answering 
to politicians, but there's no 
escaping such accountability 
in this field." 

He adds that if young doc 
tors are intimidated by testi- 
fying in court, they shouldn't 
even consider entering the 
field. "Personally, I enjoy tes- 
tifying," Petty says. "I don't 
mind being called a liar and 
having to defend my opin- 
ions, because I know I'm a 
good witness. Sometimes, 
I've testified in as many as 
four cases in a single day" 

Petty also emphasizes that forensic 
scientists must exercise extraordinary 
sell discipline and diligence to remain 
fair and impartial. "You have to be able 
to look at both sides of the question. 
Regular doctors are bound by the Hip- 
pocratic oath and convention, but 
forensic scientists are responsible for 
crafting and maintaining their own 
ethics; 80 percent of what we do is 
strictly confidential. 

"Unfortunately, too many medical 
examiners end up becoming permanent 
witnesses for the prosecution; that's 
unfair and unhealthy. After testifying in 
case after case, they can begin to take on 
an almost God-like persona. The idea 
that a medical examiner can never be 
wrong must be avoided at all costs." 

But, Petty says, the rewards of the 
field are great for those who can 
endure the challenges. "In my career, 
I've had the privilege of consoling fam- 
ilies of victims," he says. "The way in 
which you can offer some form of com- 
fort to the suffering parents of a child 
dead by suicide or SIDS, for example, 
can be an enriching experience." 




Up^jJ^S^H- 




GRAVE MATTERS: Meticulous observations 
coupled with shrewd deductions have helped 
Petty bring closure to many mysterious deaths. 



Petty has also relished the opportu- 
nities he has had to lecture to police 
and public health officials, and even 
to shape national policy. For 25 years, 
he has volunteered with the National 
Law Enforcement and Corrections 
Technical Advisory Committee, mak- 
ing recommendations on everything 
from the use of pepper spray to body 
armor. And although the strict confi- 
dentiality of so much of the work of a 
medical examiner creates it owns bur 
dens and sense of isolation, it can also 
be liberating. "Unlike most doctors," 
Petty says, "medical examiners get to 
work as they wish, free from certain 
pressures and agendas." 

Yet the most gratifying aspect of his 
field is also perhaps the most ironic. 
Although his professional expertise 
focuses on the dead, the exercise of 
that knowledge has placed him 
squarely at the center of his communi- 
ty. "Ultimately," Petty says, "I have 
worked hard to bring justice and con- 
solation to the living." ■ 

Beverly Ballaw is assistant editor of the 
Harvard Medical Alumni Bulletin. 



SPRING 2000 • HARVARD MEDICAL ALUMNI BULLETIN 



EDICAL 
DETECTIVES 



36 



ltell-tale 

heart 

An infectious disease expert investigates how human attitudes and 
behaviors can promote — or imperil — a healthy society 



SOLVING MEDICAL MYSTERIES COMES 

naturally to Judith Wasserheit 78, 
whose unconventional childhood 
made her realize that she wanted 
to be a doctor even before she 
reached kindergarten. Her early 
role model was her mother, a podi- 
atrist whose juggling act as a 
practitioner, professor, and parent 
was considered "pretty outra- 
geous" for a woman in the 1950s. 
As a child, Wasserheit often 
accompanied her mother to nat- 



ional meetings — and tagged along 
to medical lectures. 

Her mother's position as chair of 
a department of special anatomy 
offered Wasserheit other preco- 
cious exposures to medicine. "I 
grew up with feet and legs in the 
freezer at home," she recalls. "For 

o 

my 13th birthday, my mother's gift | 
was my very own cadaver. We used ! 

5 

to go to the college of podiatry and 
dissect it together. It was a fabu- s 
lous learning experience, though 



by Beverly Ballaro 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 



Like most detectives, Wasserheit is intrigued by the human 



the odor of formaldehyde had a defi 
nite impact on my social life!" 

Although her current job with the 
Centers for Disease Control and Preven- 
tion — where she is director of the Di\i- 
sion of STD Prevention — requires med- 
ical detective work on a national scale, 
Wasserheit did not always intend to 
work in the field of infectious disease. "At 
HMS, I really had no appreciation for 
public health," she confesses. "I didn't 
consider it 'hard core' enough compared 
to the other science courses I was taking." 

A rotation in a jungle hospital in 
Colombia transformed Wasserheit's 
perspective — and her future. "I was 
clobbered over the head by the glaring 
contrast between medicine as practiced 
back in Boston and in this part of the 
developing world," she remembers. "For 
the first time, I was deeply struck by the 
reality that people live either in commu- 
nities that reinforce healthy behaviors, 
or in circumstances that make healthy 
living incredibly difficult." 

The inequities that she witnessed in 
Colombia sparked Wasserheit's passion 
for studying disease and wellness in a 
broad context. "The truth is that curative 
care often comes too little and too late for 
many people in the world," she says, 
recalling one heartbreaking experience 
she had while working in a refugee camp 
in Thailand. A Cambodian girl was suf- 
fering from a congenital cardiac defect. 
Although the problem was easily cor- 
rectable by surgery, officials decided not 
to use scarce resources by sending her to 
Bangkok for the procedure, because they 
knew she would not receive the neces- 
sary postoperative care in the camp. 

Wasserheit, who completed intern- 
ships in both internal medicine and 
surgery, gravitated toward the field of 
infectious disease in part because of 
experiences such as the one in Thailand. 
"Eventually, I began to think that infec- 
tious disease was a particularly wonder- 
ful branch of medicine," she says. "Not 
only do you get to work with mostly 
young, otherwise healthy people, but 
you can actually heal them." 



Like most detectives, Wasserheit is 
also intrigued by the human stories 
uncovered in the course of solving a mys- 
tery. "In this field, you can legitimately 
ask people where they've traveled, what 
they've eaten, what pets they keep, and 
whom they've slept with — and then you 
can cure them. How many jobs allow 
you to do that?" 

Beyond Bugs and Drugs 

Conducting population-level clinical 
and epidemiologic research requires 
knowledge of both microbiological and 
sociological factors. As Wasserheit 
explains, "It's not just about bugs and 
drugs. To reconstruct events, you have 
to understand bugs and human behav- 
iors and communities." 

The trickiest investigations can 
require a delicate negotiation of linguis- 
tic sensitivities and cultural taboos. In 
one of her first forays into population- 
level research, Wasserheit carried out a 
study of risk factors for STDs among 
rural Bangladeshi women and the 
impact of such diseases on their lives. 

Local officials were initially aghast at 
the notion of asking women in this con- 
servative Muslim country about issues 
related to sex and reproduction. Wasser- 
heit quickly learned that knowing how to 
ask questions was crucial to her efforts. 
She took care to name her investigation a 
study of "reproductive tract infections" 
rather than STDs. She also framed the 
study for participants in terms of its rel- 
evance to successful childbearing, which 
was of crucial value in that society. 

To avoid having to rely exclusively on 
interpreters, Wasserheit spent six 
months in a monastery studying inten 
sive Bengali. And she paid attention to 
how she dressed; wearing Western 
clothing in a rural health center intimi 
dated local women, she discovered, so 
she traded in her white coat for a sari. 
The sari proved key not only because it 
demonstrated respect for her patients, 
but also because it signaled Wasserheit's 
status as a married woman — only a mar- 



ried woman, local culture dictated, 
could properly engage in as intimate an 
acthity as conducting a pehic exam on 
another woman. 

By helping the women understand 
the connection between their health and 
their fertility, Wasserheit was able to 
gather valuable information and pro- 
mote healthy goals. She discovered that 
rural Bangladeshi women, once made 
comfortable, actually relished the oppor 
tunity to talk about sex, their husbands, 
and other topics considered taboo. 
"Much of their initial reticence stemmed 
from living in a culture frightened of and 
conflicted about sexuality, not unlike 
what you see in many parts of our own 
society," she says. 

Lessons learned about how to negoti- 
ate such fear and ambivalence helped 
Wasserheit when she returned to the 
United States, first to join the faculty at 
Johns Hopkins, and later to serve as the 
first chief of a national STD research 
branch at the National Institutes of 
Health. As she began working with a 
population of young, indigent, and poorly 
educated women, she was startled to find 
the conditions in Baltimore remark- 
ably — and depressingly — similar to 
those she had encountered in Bangladesh. 

Motives and Opportunities 

In her current position at the CDC, 
Wasserheit oversees investigations at 
multiple levels. Sometimes, the mystery 
in question involves an outbreak on a 
large scale. Wasserheit's division has 
been working with local public health 
officials, for example, on newly emerg- 
ing resistances to antibiotics for gonor- 
rhea in locations as far-flung as Kansas 
and Hawaii. 

But often the challenge has less to do 
with tracking down bugs than stirring 
up people; it is Wasserheit's responsi- 
bility not only to oversee her division's 
research, but also to produce results 
across the nation. She acknowledges 
that changes in policy struggle to keep 
pace with research breakthroughs. 



38 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 



Tories uncovered in the course of solving a mystery. 



"Translating research into routine 
practice is incredibly difficult," Wasser- 
heit says. "Most research is conducted in 
rarefied environments, but in the real 
world, there are issues around training, 
staffing, financing, politics, and some- 
times just plain old inertia." 

The gap between knowledge and 
practice can be maddening. Wasserheit 
points out one study's conclusion that 
two appropriately designed 20'minute 
counseling sessions in STD clinics 
increased condom use as effectively as 
more elaborate, expensive interventions, 
but the simpler, cheaper solution has yet 
to become standard practice anywhere 
in the country. Another study, by Seattle 
investigators, demonstrated that selec 
tive screening and treatment for chlamy 
dia for women in managed care can 
reduce pelvic inflammatory disease by 
an astonishing 60 percent; such screen- 
ings are not yet routine in the United 
States, even in the very practices in 
which the study was conducted. 

Despite such frustrations, Wasserheit 
enjoys her successes and derives satisfac- 
tion from making a difference on a 
national level. "We are moving, albeit 
incrementally and painfully, in the right 
direction," she says. "People are begin- 
ning to appreciate that health can 
be achieved through community- wide 
collaborations and mobilizations." 

She notes, for example, that syphilis 
rates over the past two years have been 
the lowest ever recorded, and that a tiny 
fraction of communities account for a 
staggering percentage of the cases that are 
reported. To meet the surgeon general's 
announced goal of eliminating syphilis by 
2005, Wasserheit and her colleagues have 
been working with those communities at 
risk to understand why they are vulnera- 
ble, and to help them take sustainable 
actions to improve their health. 

What the investigators have confirmed 
is that the map for syphilis looks striking- 
ly similar to the maps for HIV infection, 
high infant mortality rates, and shortened 
projected lifespans. "Clearly," Wasserheit 
says, "the barriers are not biomedical in 




SMALL WORLD: Working for healthy mothers and babies has brought 
Wasserheit to communities around the globe, including some in Bangladesh. 



nature. We can detect and cure syphilis. 
The real mystery lies in how to overcome 
the societal issues that perpetuate this 
highly stigmatizing disease. It's a question 
of coming to grips with fractures in the 
health care system, substance abuse, and 
racism. Until we, as a society, can look 
each other in the eye and not only say that 
we're all equals, but really believe it, we're 
going to have to suffer the consequences." 

Future Challenges 

As a physician, but especially as the 
mother of a six-year-old son, Wasserheit 
is committed to puzzling out the causes 
of — and solutions to — some of the coun- 
try's toughest health challenges. She is 
especially passionate in her contention 
that society must do a better job of 
teaching all young people how to estab- 
lish healthy behaviors early in life. 

Last summer, when she worked with 
other researchers and public health offi- 
cials examining health services for ado- 
lescents in the San Francisco Bay Area, 
Wasserheit learned that, particularly for 
teens considered high risk, the issue was 
not usually a lack of appropriate and 



accessible resources, as many had 
assumed. The problem often lay, instead, 
in the reality that these young people did 
not feel valued and, consequently, did 
not perceive investing time and energy 
into their health as a priority. Changing 
this perception is crucial, she believes, to 
the future health of society. 

Reflecting on the kind of nation she 
would wish for her son by the time he 
reaches adolescence, Wasserheit is cau- 
tiously optimistic that some of our most 
urgent medical mysteries will be, if not 
solved at least manageable. She envisions, 
for example, that scientific break- 
throughs will lead to vaccines and home- 
based tests for several STDs. Just as fer- 
vently, however, she hopes for fundamen- 
tal shifts in human attitudes. Her \ision 
for the future features a society in which 
people can talk openly abut healthy sexu- 
ality adolescents feel connected to com- 
munities that value their health, and race- 
based disparities in care have been dra- 
matically lessened, if not eliminated. "And 
that," she says, "is a pretty tall order." ■ 

Beverly Ballaro is assistant editor of the 
Harvard Medical Alumni Bulletin. 



SPRING 2000 ■ HARVARD MEDICAL ALUMNI BULLETIN 



39 



iEDICAL 
ETECTIVES 



by Anthony S. Patton 



MURDER 



SCENE OF THE CRIME: 

John Webster's chemistry 

laboratory was located 

in the basement of 

Harvard's medical 

college (right), which 

faced Massachusetts 

General Hospital (left). 



ON THE MORNING OF NOVEMBER 23, 1849, GEORGE PARKMAN 

donned a purple silk vest, a dark frock coat and trousers, 
and a black stovepipe hat. He strode purposefully through 
the West End of Boston, his lower jaw jutting forward in 
the characteristic way that had earned him the moniker 
"The Chin." He collected rent from several tenants, pur- 
chased a head of lettuce at Quincy Market for his ailing 
daughter, and stopped to order butter and sugar from a 




40 HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 







A brutal slaying at Harvard 
Medical School led to one of 
the world's first applications of 
forensic evidence in court 



AHD 



i 

y 

a 

s 







I 







eorge Parkman did not leave the building alive. 



local grocer. He then mounted the 
steps of Harvard's medical college,* a 
building that had been opened, amid 
much pomp and circumstance, just 
three years earlier on land donated by 
Parkman himself. 

Parkman regarded the medical col- 
lege as something of a jewel in his real 
estate empire and proudly called 
it "a piece of the Holy Land." Dur- 
ing that Friday before Thanksgiv- 
ing, however, the medical college 
was about to play host to events 
far removed from the sacred; 
George Parkman, esteemed Har- 
vard alumnus, physician, and real 
estate mogul, did not leave the 
building alive. 

In 33 years of marriage, Parkman 
had never before missed his two 
o'clock dinner. After staying up all 
night awaiting his return, his tear- I 
ful wife at last summoned relatives, 
who immediately suspected foul 
play. Handbills were distributed 
and generous rewards offered. 
Wild rumors about Parkman's 
whereabouts percolated through- 
out the city. For a full week, = 
Bostonians ransacked Parkman's 
West End tenements, interrogated 
bridge and turnpike attendants, 
and dragged the Charles River. 
Police searched the medical college 
and combed the marshy wooded 
land beyond the hospital. In the 
growing climate of hysteria, an Irish- 
man was detained for questioning 
when he tried to pay a toll with a 
twenty-dollar bill; no Irishman, the 
thinking went, could possibly have 
come upon that much money by hon- 
est means. 



Two days after Parkman mysteri- 
ously vanished, his wife received a 
visitor. John White Webster, a long- 
time family friend, stopped by to 
inform the Parkmans that he had 
seen George the afternoon of his dis- 
appearance, at which time he had 
paid the doctor his debt in full. Web- 



AWFUL DIB0LO8TmB8 

STARTLING DEVELOPEMENTS, 

II KKLATIOH TO THX LaTT 

PARKMAN TRAGEDY. 






rrnffinr 



r.TB A rVU. ACCOVWT OF TBI DMOOFUT OF THI tMMkJMl OF TKM 
L*TX Dft. GbOMI PaUMAV, A*t> TSB SV*»QPB»T AMMWT OF 

PROFESSOR JOHN W. WEBSTER. 



A 



AWFUL DISCLOSURES: A trial pamphlet 
provided inquiring minds with details 
of the Parkman murder case. 



ster's cold, detached demeanor took 
the Parkmans by surprise; Parkman, 
after all, had not only lent Webster 
considerable money over the years, 
but had also played an instrumental 
role in Webster's faculty appoint- 
ment at Harvard's medical college. 



Their surprise quickly turned to a 
nagging suspicion that would soon 
help set in motion what became the 
most sensational trial in nineteenth 
century America. 

The Bitter Brahmin 




At age 59, Parkman cut a distin- 
guished, if austere, figure among 
Boston's elite. Tall and almost 
painfully thin, with a demeanor that 
suggested discipline and righteous- 
ness, he had elicited the admiration 
of the dean of Harvard's medical 
college. Oliver Wendell Holmes, 
who stated, "He abstained while 
others indulged, he walked while 
others rode, he worked while others 
slept." Parkman had parlayed his 
sizable inheritance into a real estate 
fortune, and he exuded an air of 
smug self-satisfaction. Ever the fru- 
gal Yankee, he refused to keep a car- 
riage. Every day the citizens of 
Boston could set their watches by 
the rounds he made on foot, collect- 
ing rents and conducting his busi- 
ness with a punctiliousness that 
some thought occasionally bor- 
dered on cruelty. 

.Although his family was rich, 
generous, and powerful, Parkman's 
life had seen its disappointments. 
His daughter was sickly, and his son 
had not lived up to his expectations. 
Most irksome of all, he had not realized 
his dream of becoming a pioneer in the 
treatment of mental illness. Early in his 
career, after attending lectures at Har- 
vard's medical college and earning his 
medical degree in Scotland, he had 
spent time observing the work of 



PROFESSION 



LAST SEEN 



THE VICTIM 



DR. GEORGE PARKMAN 



Real estate entrepreneur, 
physician, and 
philanthropist 



Entering Harvard's medical college 
around one o'clock on Friday, 
November 23, 1849 



42 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 



*At the time of Parkmans murder. Harvard \ ledical School was called Massachusetts Medical College. 




PARKMAN STRODE ALONG TREMONT STREET ON HIS FINAL JOURNEY THROUGH BOSTON 



physician Philippe Pinel at an insane 
asylum in Paris. At that time, treatment 
for those with chronic mental illnesses 
tended to be primitive and punitive. 
Inmates suffered under harsh condi 
tions and were often chained to walk. 
Pinel instead espoused kindness for his 
patients. He released their chains, fed 
them nutritious food, and tried to cre- 
ate a healthy program of exercise and 
fresh air. The young Parkman was 
greatly impressed with the exciting 
results of this new treatment. 

Parkman returned to the United 
States planning to help start the Mass- 
achusetts Mental Hospital — now 
McLean Hospital — and even provided 
seed money for the project. Officials at 
Massachusetts General Hospital had 
agreed to the idea, and Parkman was 
keen to be the new superintendent. He 
was crushed to learn, however, that 
despite his position, wealth, and quali 
fications, he had been passed over in 
favor of another physician. He took the 
rejection hard and turned much of his 



attention to managing his family's 
enormous real estate holdings. 
Nonetheless, as the author of Remarks 
on insanity and The Management of 
Lunatics, he was occasionally called to 
court to testify as to the motives and 
mental states of violent crimi 
nals, and so he continued to be 
regarded as an authority on 
mental illness. 

Skyrocket Jack 

Like Parkman, John Webster, 
professor of chemistry at the 
medical college, hailed from 
one of Bostons wealthy and 
prestigious old families. He had 
earned his undergraduate degree 
from Harvard two years behind 
Parkman, then his medical degree 
from Harvard in 1815. He had 
married an ambassador's 
daughter, trained at Guy's 
Hospital in London, writ 
ten a college chemistry 



textbook, and helped found the New 
England Journal of Medicine 

Yet Webster sported a frivolous 

side. In sharp contrast to Parkman, the 

shrewd and sober Yankee, Webster 

had a reputation as something 

of a self indulgent dandy; he 

enjoyed eating, drinking, and 

playing cards, and he had 

earned the nickname "Skyrocket 

Jack" for his insistence on a 

flashy display of fireworks to 

mark the inauguration of 

Harvard's president. 

For all his genteel man- 
ners and associations, the 
professor harbored an explo- 
sive temper, and trouble 
always seemed to be brewing 
in his life. As an undergrad- 
uate, he had been subject 
to disciplinary action for 
rude and unruly behavior. 
During one spirited dis- 
cussion, Webster struck 
a fellow student with 



Friday, November 30, 1 849 
in various hiding places 
around the medical college 



CAUSE OF DEATH 



A blow to the head with a 
large stick; his body was then 
dismembered and burned 










SPRING 2000 • HARVARD MEDICAL ALUMNI BULLETIN 




ebster proclaimed his innocence, demanded to seel 



his cane, a blow that could have been 
fatal had it landed on its target's head. 
On another occasion, Webster 
attacked a colleague in a barbershop 
for an uncomplimentary remark 
meant as a joke. Even family members 
questioned exactly what happened at 
Guy's Hospital when he was forced to 
leave abruptly. There were whispers of 
violence, even assault and rape. 

Disturbing questions about Web- 
ster's behavior trailed him into adult- 
hood. When a chemistry experiment 
he performed caused an explosion, 
nearly injuring a student, Webster triv- 
ialized the episode in an unpleasantly 
cavalier fashion. On another occasion, 
he cruelly beat a stray dog to demon- 
strate head injuries. And then there was 
the destitute cousin whose meager 
inheritance Webster was rumored to 
have stolen. It did not help that his stu- 
dents disliked him and laughed at him 
during lectures. 

For the most part, however, Web- 
ster seemed to fit in well with the 
other professors. He lived in fine fash- 
ion not far from Harvard Square, in a 
series of large houses with all the 
amenities, including servants. The 
Websters hosted many parties, and 
their daughters always had the finest 
tutoring and music lessons. Their 
friends included the intelligentsia and 
social elite of the time. 

Unfortunately, Webster's extrava- 
gant tastes exceeded 
his means. He had 
frittered away a 
family inheri- 
tance, spending 
lavishly to amass 
a fine mineral col- 




lection and squandering $3,000 on the 
purchase of the skeleton of a woolly 
mammoth. His lectures, which were 
supported by student subscriptions, 
did poorly, and his $l,200-a-year 
stipend from the medical college was 
soon to be cut by almost one-fifth. His 
family had already been forced to move 
once and, as their resources dwindled, 
he became concerned about losing then- 
house again. In desperation, he began to 
borrow heavily from friends. Finally, he 
had no choice but to offer up his miner- 
al collection as collateral for a loan from 
George Parkman. When, purely by 
chance, Parkman discovered that Web- 
ster had put up his collection as collat- 
eral for another loan, he felt that he had 
been swindled and became enraged. 

Parkman, who had known Webster 
for decades, was well aware that Web- 
ster lived beyond his means and was 
only a mediocre professor. Despite his 
sour disapproval of what he regarded 
as Webster's excesses and deficien- 
cies, Parkman had agreed to lend him 
money partly out of sympathy for 
Webster's family. When he became 
convinced that Webster had defraud- 
ed him, however, Parkman began to 
hound the professor, publicly accost- 
ing him about the debt. He would 
haunt Webster's Harvard lectures, 
waiting in the back of the hall to con- 
front the professor after class, speak- 
ing loudly so others could hear. He 
threatened exposure and intimated 
that Webster's professorship was at 
stake. He was relentless in demanding 
satisfaction. On the morning of the 
disappearance, Webster went to Park- 
man's house to schedule an appoint- 
ment for that afternoon. 



Pieces of the Puzzle 

In its fifth and penultimate location 
since its creation in 1782, Harvard's 
medical college squatted on the tidal 
flats of the Charles River facing Mass- 
achusetts General Hospital. The red 
brick building served as the main loca- 
tion for lectures. Classes were held on 
the top two floors, and the basement 
housed Webster's chemistry laborato- 
ry, the dissecting room, and the living 
quarters of the janitor's family. Below 
the basement was a large pit sur- 
rounded by brick for the disposal of 
cadavers; a similar yet smaller struc- 
ture encased the hole beneath Web- 
ster's private privy. 

Several witnesses had observed 
Parkman enter the door of the medical 
college on the day of his disappearance, 
but no one had seen him exit. The 
police knew that Parkman had been at 
the school, so they initiated a search 
that included the chemistry laboratory. 
As it turned out, their initial explo- 
ration proved not thorough enough. 

It was not the authorities, but 
Ephraim Littlefield, the janitor, who 
most doggedly suspected the profes- 
sor. He noted that Webster began to 
lock his laboratory door at all times. 
He also realized that the furnace in 
Webster's laboratory was being 
stoked with a great deal of wood; its 
heat could even be felt through the 
wall. Behind the locked door, Eittle- 
field could hear the sound of constant- 
ly running water. Most telling of all, 
since Parkmaris disappearance, Web- 
ster had turned uncharacteristically 
genial. When Webster gave the janitor 
a Thanksgiving turkey, the first gift he 
had offered in seven years, the gesture 



THE PERPETRATOR 

DR. JOHN 
WHITE WEBSTER 



PROFESSION 



Professor of chemistry 
at Harvard's medical 
college 



THE CRIME 



The grisly slaying of 
George Parkman, real 
estate entrepreneur 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 



lis family, and blurted, "Did they find all the body?' 



only heightened Littlefield's sus- 
picions. It occurred to him that 
the police had yet to search the 
professor's private privy. 

While the gift of Webster's 
Thanksgiving turkey cooked in his 
quarters above, and with his wife 
standing guard, Littlefield under- 
took the hard, cold, wet climb to 
reach the crawl space in the lower 
basement of the medical college. 
On his own hunch at first, then 
with the approval of two of the 
medical college professors, he 
began to chisel his way through 
five layers of bricks to reach the 
privy vault. When he finally broke 
through, after several hours of 
cramped, odorous, and unpleasant 
labor, an appalling sight awaited 
him. Upon glimpsing three fresh 
body parts — a pelvis, a complete 
thigh from hip to knee, and the 
lower part of a leg — Littlefield 
bolted for help. 

That night, the police transport- 
ed the shocked Webster from his 
home to the Leverett Street jail and 
charged him with Parkmaris mur- 
der When they dragged him to his 
laboratory to bear witness to their 
discoveries, Webster became increas- 
ingly distraught. He proclaimed his 
innocence, demanded to see his family, 
and blurted, "Did they find all the 
body?" He began to twitch uncontrol 
lably and sweat profusely. It was later 
discovered that when Webster arrived 
at the jail, he had surreptitiously swal- 
lowed a strychnine pill, which almost 
killed him. 

The next day, police officers, coro- 
ners, and other experts swarmed 







EXHIBIT A: When dentist Nathan Keep 
testified using plaster casts of Parkman's 
jaw, he became the first to offer in court 
odontological evidence to identify a body. 



the medical college. While Webster 
sobbed in jail, the authorities were 
making a series of gruesome discover- 
ies in his laboratory. Guided by an 
unpleasant odor, they were horrified 
to unearth from the depths of a wood- 
en tea chest a large, half-burnt head- 
less torso, with curling gray hair 
thickly covering its back. The victim's 
head had apparently been sawed off 
rather crudely. When the investiga 
tors loosened a cord encircling the 



torso, they realized that it had 
been eviscerated to make room 
for a thigh. More grisly bits of 
evidence emerged from the ashes 
in Webster's furnace: pieces of 
burnt bone, viscera, and — 
although officials didn't realize it 
at the time — the clue that would 
seal Webster's fate: a dental plate 
with two teeth still attached. 

A Weil-Appointed Jail Cell 

Within several days of his arrest, 
Webster had recovered from his 
strychnine poisoning and had 
begun to develop a defense. Even 
so, he did not seem to understand 
the gravity of his situation. It was 
clear from the beginning that 
Webster was not about to con- 
fess, and no lawyer would take 
the case. Finally, the court had to 
appoint two lawyers. 

Webster, in the meantime, ded- 
icated himself to making his cell 
comfortable, and he had family and 
friends send in all sorts of delica- 
cies: fruit from the Azores, fine 
cheeses, Madeira tea, imported 
cigars. His fellow professors and 
even the president of Harvard visited 
him to express their support. Many of 
his Harvard Square cronies took up the 
theory that Webster's plight stemmed 
from the inability of Bostonians to 
understand a Cambridge gentleman. 
They found it impossible to believe that 
he could be connected with such a 
heinous crime. He was, after all, a Har- 
vard professor. 

While his lawyers scrambled to 
confront the mass of damning evi- 



THE MOTIVE 



George Parkman's insistent 
demands for payment of 
debts totaling $483.64 



THE ALIBI 



A note allegedly signed 
by Parkman that cleared 
Webster of his debts 



THE VERDICT 



Guilty as charged for the 
crime of willful murder 



THE SENTENCE 



Death by hanging, 
on August 30, 1 850 



SPRING 2000 • HARVARD MEDICAL ALUMNI BULLETIN 




ore than 60,000 people came to witness the spectacle. 



dence against him, Webster continued 
Co make the most of his time in jail, 
transforming his stay there into a sort 
of college reunion. All of his friends 
from Boston's genteel circles — the 
Lowells, Treadwells, Cunninghams, 
Bigelows, and Feltons — descended 
upon the jail to pay a visit to its 
celebrity inmate. Webster held court 
every day, filling up on wine, fine food, 
and repartee. His lawyers pleaded 
with him to be more realistic, but 
Webster never wavered. He continued 
to deny the overwhelming evidence 
against him, just as he had denied his 
strangling debt. 

Webster stubbornly clung to his 
alibi: on that fateful Friday, he said, he 
had asked Parkman to visit his labora- 
tory. He gave Parkman the $483.64 
owed him, and Parkman took the note, 
signed it as paid, and left. Webster stat- 
ed that he had no knowledge of whose 
remains were in his laboratory; if they 
were Parkman's, Webster certainly had 
nothing to do with his demise. 

No matter how often his attorneys 
inquired, Webster insisted that he had 
no idea how the dismembered body 
ended up in his laboratory. He even 
hinted at dark conspiracies by others to 
claim the reward money. Webster 
would not permit discussion of any 
alternative version of his story, and he 
seemed to think that his lofty social 
position would answer any case the 
prosecutors might create. 

The Trial of the Century 

Webster's trial, which lasted 11 days in 
March 1850, was considered to be the 
most sensational legal proceeding of 
the nineteenth century. The press 
swarmed everywhere, and the crowds 
milling around the courthouse were 
always large and noisy. More than 
60,000 people came to witness the 
spectacle; to accommodate the crowd, 
the Boston police rotated people in 
and out of the courthouse gallery 
every ten minutes. If they expected to 



see a gaunt, evil phantom in the dock, 
they were disappointed, for the 
already portly Webster had gained 20 
pounds while in prison. 

The prosecutors began with the 
motive: Webster was being hounded by 
Parkman for an unpaid debt. Littlefield 
then testified about Webster's odd 
behavior, the constantly stoked furnace 
and running water, and his discovery of 
body parts beneath the privy. The pros- 
ecutors went on to describe the profes- 
sor's behavior on the night he was 
arrested, and to point out that Webster 
had been found carrying not only the 
note canceling his debt, but also a sec- 
ond note involving other creditors that 
Parkman would never have surren- 




EXHIBIT B: Parkman's skeleton was 
reconstructed using more than 1 50 
bones, fragments, and body parts. 



dered to Webster. They then presented 
a series of letters that had been sent to 
authorities anonymously. In different 
scrawls, these letters named other pos- 
sible suspects and provided fictitious 
reasons for Parkman's disappearance. 
Handwriting experts verified that 
Webster not only had penned those let- 
ters himself, but had also forged Park 
man's signature on the paid note. 

Then there was the overwhelming 
physical evidence collected from the 
scene of the crime. Police had found 
Webster's overalls and carpet slippers 
spattered with blood. They had recov- 
ered his jackknife and butcher's saw, 
which had apparently been used to dis- 
member the body. And Parkman's 
grie\ing widow had identified distinc- 
tive marks on what was left of the 
corpse's back and genitalia. 

From the beginning, Webster's 
defense team faced an uphill battle, 
yet they made a valiant effort. His 
lawyers produced several people who 
swore that they had seen Parkman 
hours after he was supposed to have 
been killed. Others testified to Web- 
ster's concern about Parkman's disap- 
pearance, as well as Webster's fine 
character and cheerful demeanor 
around the time that he was alleged to 
have committed the brutal murder. 
The evening of the fateful day, in fact, 
Webster had played whist, recited 
poetry aloud to his daughters, and 
deliberated with friends the best 
method of preserving wedding cake. 

Moreover, Webster's attorneys argued, 
the case was circumstantial. Who 
knew if the remains were even those of 
Parkman? Perhaps someone else's body 
had been stuffed in the privy. In the 
end, however, Webster's defense team 
could not overcome the powerful evi- 
dence that the prosecutors had already 
methodically set forth. 

The piece of evidence that eclipsed 
all doubt also set an important prece- 
dent in medical jurisprudence. In one 
of the first successful applications of 
forensic medicine in a court of law, 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 




{ # Heo«>j whrre Tea Chen was found 
_JA F A_<sa>- Furnace I F Funuu: 

J\rfeiTru:«aw.TCh-Tow r Hm^ 

/Dp Ptwv I *. i>i» b i 



THE UPPER BASEMENT OF THE MEDICAL COLLEGE 



authorities made a positive identifica- 
tion of Parkman's corpse using the jaw 
and set of teeth that they had recovered 
from the furnace in Webster's laborato- 
ry. Investigators had sent this evidence 
CO Parkman's dentist, Nathan Keep 
(later appointed the first dean of the 
Harvard School of Dental Medicine), 
who identified the false teeth as being 
those of Parkman. 

On the stand, Keep — a close friend 
of both the murder victim and the 
accused — demonstrated how the origi- 
nal mold he had cast for Parkman per 
fectly matched the jaw found in the fur 
nace. He wept as he recounted how he 
had finished filing down the teeth just 
in time for a special occasion for Park- 
man — the 1846 dedication of Harvard's 
medical college building on Parkman's 
"piece of the Holy Land." 

Murder Will Out 



The jury delivered a guilty verdict in 
just three hours. The jurors seem to 
have felt pity for Webster, for they 
spent all but five minutes of the delib 
eration period in prayer, eager "to put 
off the sorrowful duty." Two days 
later, Webster was sentenced to death 
by hanging. When the sentence was 
read, he began sobbing, and his fore 
head fell abruptly against the bar of 
the prisoner's dock. 



Webster tried two appeals, one that 
stated his innocence, then a second one 
in which he confessed to the crime, at 
the urging of a local minister. His con- 
fession portrayed him as the victim of 
Parkman's vindictiveness. When they 
met in the chemistry laboratory that 
Friday afternoon, Webster recounted, 
Parkman had thundered at him, "I got 
you into your position, and now I will 
get you out of it!" 

"While he was speaking and gestur- 
ing in the most violent and menacing 
manner," Webster stated, "I seized 
whatever thing was nearest me, a stick 
of wood, and dealt him a blow with all 
the force that passion could summon. I 
did not know, nor think, nor care where 
I should hit him, nor how hard, nor 
what the effects should be. He fell to 
the floor instantly. He did not move." 

Webster claimed that he then pan- 
icked, carved up Parkman's body, 
burned the parts that fit in the fur 
nace, and stuffed the pieces that were 
too big into the privy hole and the tea 
chest. "All I could see was the need to 
conceal Dr. Parkman's body," Webster 
explained, "in order to avoid the 
blackest disgrace." 

But there was too much to excuse, 
and too many inconsistencies to 
resolve. Webster had invited Parkman 
to come to his laboratory even though 
he had no means of paying off the debt. 



He had not summoned help after Park- 
man fell, and he had dismembered 
Parkman's body in a most horrible 
fashion. Webster's confession came 
too late. Despite the outcries against 
capital punishment that sounded 
throughout New England, his appeal 
was refused. 

John Webster was hanged on 
August 30, 1850. He had requested 
that his wife and daughters not be told 
in advance the date of his execution. 
The jail, however, had many leaks of 
information, and a crowd gathered to 
witness the hanging. The night of the 
execution, under cover of darkness, a 
crew led by one of his lawyers spirited 
Webster's body away and buried him 
in an unmarked grave, perhaps on 
Copp's Hill. His family never knew his 
burial place. 

After Webster's death, many of the 
Brahmin rallied to raise money for his 
impoverished widow and daughters. It 
is said that the first contribution — a 
check for $500 — came from Mrs. 
George Parkman of Boston. ■ 

Anthony S. Par ton '58 is a retired thoracic and 
vascular surgeon whose career was centered 
at Salem Hospital. Patton attended HMS 
despite his mother's concern that medicine 
was a poor choice for a profession, for she 
believed it would always he tainted by John 
Webster's terrible act. 



SPRING 2000 • HARVARD MEDICAL ALUMNI BULLETIN 



47 



BABY ON BOARD 
In eastern Ken- 
tucky, isolation 
and treacherous 
terrain used to 
jeopardize the 
lives of mothers 
and newborns. 





A surgeon recounts his adventures working 
alongside nurse-midwives in one of the poorest 
and least accessible areas of the United States 



by Frank J. Lepreau, Jr 



IN THE EARLY DAYS OF THE FRON- 
tier Nursing Service, nurse- 
midwives navigated eastern 
Kentucky's rough terrain on 
horseback. One day, so the legend 
goes, a young boy inquired of his 
expectant mother, "Mama, where 
do babies come from?" "Why," she 
answered, "the midwives bring 
them in their saddlebags." Since 
then, this story has been passed 
on throughout Kentucky's moun- 
tain communities. 

Eastern Kentucky is all hills and 
hollows, and in the tiny town of 
Hyden, nestled at the bottom of 
one of those hollows, it is said that 
the only way to see the sun shine is 
to lie on your back between 10:00 
a.m. and 4:00 p.m. I first arrived in 
Hyden in 1973 to embark on a two- 
year stint as the medical director 
of the Frontier Nursing Service, a 
pioneering program that trains 
and sends nurse -midwives to the 
homes of expectant mothers. 
There I found a primitive wooden 
hospital with a single operating 
room the size of a large closet. 



Breckinridge was involved in all details, including matching 
the temperaments of the horses with those of the midwives. 



MAKING ROUNDS: 
Frank J. Lepreau, Jr. 
'38 walks behind a 
Frontier Nursing Service 
jeep in 1975. The jeep 
had replaced the horse 
as the principal means 
of transporting medi- 
cal personnel through 
eastern Kentucky. 



complete with a wet mop and mousetrap in 
the corner. Fortunately, my previous experi- 
ences in Haiti and Kenya had accustomed me 
to working with a minimal support system. 

As the service's only surgeon, I performed a 
fair amount of complicated surgery and many 
Caesareans, although Anne Wasson, a general 
practitioner, also performed Caesareans and 
many other surgical procedures. I quickly dis- 
covered, however, that years of exposure to the 
Frontier Nursing Service had taught the local 
women that a surgeon's skills were secondary to 
those of the trusted nurse-midwife. It was not 
long into my tenure before I, too, began to share 
a profound respect for the competence and 
devotion with which the midwives served their 
patients in this hardscrabble region. 

Heroines on Horseback 



In the early 1900s, American women were 
more likely to die in childbirth than from any 




disease other than tuberculosis. The mortality 
rate was especially high in rural areas, where 
doctors and hospitals were scarce. And in east- 
ern Kentucky, where women married young 
and gave birth to an average of nine children, 
isolation and tricky terrain further jeopardized 
the lives of mothers and their newborns. 

In 1925, after the deaths of her own two 
young children, Mary Breckinridge, a nurse- 
midwife with Kentucky roots, founded the 
Frontier Nursing Service. At first, the nurse- 
midwives all had to be imported from England, 
the only country that trained women to practice 
both professions. Later, when World War II 
began, the nurse-midwives returned to Eng- 
land. That did not deter Breckinridge, who then 
founded a midwifery school. 

In fact, Breckinridge devoted her life, income, 

and energy to the people of eastern Kentucky, 

with a particular concern for pregnant women 

and their children. "Work for children should 

begin before they are born, should carry them 

through their greatest hazard which is 

childbirth, and should be most intensive 

during their first six years of life," she 

wrote. "These are the formative years — 

whether for their bodies, their minds, or 

their loving hearts." 

Breckinridge was amazingly successful. 
Her work centered in Hyden, whose pop 
ulation even today is less than 500. She 
founded Hyden Hospital and, inspired by 
a similar network in the Hebrides, devel- 
oped six outpost nursing stations, each 
located one day's horseback ride from the 
next. The stations represented a lifesaving 
contribution to the region, because the 
few roads that existed were mostly dirt, 
often muddy, and sometimes completely 
flooded. There were no telephones, so all 
communication took place by short wave 
radio or courier. 

Two registered nurses, one of whom 
was a certified nurse-midwife, lived at 
each station. These women performed the 
deliveries and attended to all other health 
care needs in a 700-square-mile area. 
They provided prenatal services, visiting 
their patients biweekly until the seventh 
month and weekly thereafter. To reach 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 




•^— — r 



* 



i , 




their patients, they would ride their horses up 
mountains and across streams, often fighting 
their way through blizzards, floods, and 
blinding fog. 

Breckinridge was involved in all the details 
of the service, including matching the tem- 
peraments of the horses with those of the mid- 
wives. She made riding lessons mandatory 
after one frightened midwife held the reins of a 
horse so tightly that Breckinridge had to res- 
cue the horse, which she described as being 
drawn up on his hind legs, with imploring eyes 
and "forepaws wagging like a dog's." 

Breckinridge even found someone to cus- 
tom-make the nurses' saddlebags for $13 a 
pair. Each nurse had two bags, one with a 
white lining for midwifery needs, the other 
with a blue-checked lining for general nurs- 
ing. When packed with supplies, the mid- 
wifery bags weighed as much as 30 pounds. 
"The utmost care has to be taken to have the 
weight evenly distributed or there might be 
trouble with the horse's back," Breckinridge 
wrote. "A bad back on a horse in the Frontier 



Nursing Service has always been the same 
kind of disgrace as a bad back on a patient in 
a hospital bed." 

The nurse-midwives continued to rely on 
horses to reach their patients until coal mining 
became very active. The coal trucks would 
careen around treacherously narrow, often wet 
or icy roads. These trucks made traveling on 
horseback too dangerous, so the nurse-mid- 
wives switched to jeeps. 

In the service's early days, a physician also 
would make the rounds of the nursing stations 
on horseback, visiting each one of them during 
the course of a week By the 1970s, roads had 
improved enough to allow jeeps to replace 
horses as the most efficient means by which 
physicians could make their rounds. Even so, I 
once had to drive a jeep up a stream to make a 
house call. 

Between 1925 and 1975, the Frontier Nurs- 
ing Service boasted a remarkable record of 
\7,000 deliveries with only eleven maternal 
deaths. Almost all of the deliveries were in the 
women's homes, often in primitive conditions. 



HORSE CALLS: A 
nurse-midwife sits 
astride her horse at 
Red Bird, one of the 
outpost stations of 
the Frontier Nursing 
Service. Nurses new 
to the service were 
required to take 
riding lessons. 



SPRING 2000 • HARVARD MEDICAL ALUMNI BULLETIN 



51 




ROAD LESS TRAVELLED: 
For several months 
during the year he 
graduated from HMS, 
pediatrician Edwin 
Adams Harper '31 vol- 
unteered at the Fron- 
tier Nursing Service. 



These nurse -midwives not only were skilled in 
handling cases, but were also cognizant of 
when it was necessary to call for a physician or 
to transport a patient to a hospital with the 
appropriate equipment. 

By the time I joined the service, the danger of 
having an obstetrical disaster was remote, 
because the prenatal care was great, the nurses 
were fantastic, and the roads were good enough 
to allow most births to take place in a hospital. 

A World of Difference 



I jumped at the opportunity to join the Fron- 
tier Nursing Service when I spotted a notice in 
the New England Journal of Medicine soliciting a 
medical director. The service was well known 
among missionary groups and other "do-good- 
ers," and I had been hearing positive reports 
about its work for some time. 



If an old washing machine 
fact, abandoned washing! 



I had just returned to my clinic in Fall River, 
Massachusetts after spending ten years in 
Haiti. Despite the warm welcome home, I 
found myself in a state of culture shock; when 
I attended a fancy event on the Cape, I was 
appalled to see food thrown away so casually 
when, just two weeks earlier, I had been sur- 
rounded by starving people. 

So I fled modern America and again found 
myself working among impoverished and 
needy people. My wife and I lived right on the 
grounds of the service, in a house balanced 
precariously on the side of a steep hill. The 
angle of descent was so sharp that, several 
years before we arrived, the house had slid par- 
tially free of its foundation, shattering all of its 
pipes in the process. 

I liked eastern Kentucky, but when we lived 
there from 1973 to 1975, daily living could be 
bleak. Although there were some well-kept 
houses with flower gardens, on my house calls, 
I would often see a small stove with loose coal 
piled up nearby, and the house would be a 
handyman's special. Wash was usually hung 
out on the porch, and if an old washing 
machine broke, its owners would roll it down 
the closest hill. In fact, abandoned washing 
machines, refrigerators, and automobiles lit- 
tered the streams. 

Eastern Kentucky was then, as it is now, a 
gun culture. Pickup trucks would have rifles 
slung along the back windows of the cabs, and 
my scrub nurse even carried a derringer. 
Repeated trespassing despite several warnings 
by the owner might result in a shooting, some- 
times fatal. A perfunctory trial would usually 
exonerate the owner. 

During my tenure there, some counties had 
to go "dry" because of problems with alco- 
holism, and moonshiners were still making 
illegal whiskey. One morning, as the nurses 
came to work, one of them commented, "There 
sure were a lot of fireworks on Asher's branch 
last night." When I asked what she meant, she 
replied, "There were a lot of gunshots because 
the Feds were raiding a still." 

Unemployment rates also ran high. The 
main source of income was soft- coal mining — 
which was in fast decline — and lumbering. 
(Indeed, the official post office was Thousand- 



52 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 



oroke, its owners would roll it down the closest hill. In 
nachines, refrigerators, and automobiles littered the streams. 



sticks, named for the density of the trees.) 
Strip and long wall mining were the cheapest 
ways to get coal, but they ravaged the land 
scape and the health of local residents. 

I descended into the mines on four occa- 
sions. I can recall traveling a mile deep into the 
earth, transported there by a man car, an open 
vehicle in which I had to sit in a half reclining 
position, so my head wouldn't hit the roof of 
the mine. 

In the mines, the men worked three faces 
simultaneously. At one, a shooter would drill 
into the face of the coal seam for three feet, 
then stuff the hole with dynamite. When 
ready, an operator would yell, "Fire, fire!" and 
push the plunger down. A face of loose coal 
would then tumble down. The shooter would 
move to another face and repeat the proce- 
dure. He was followed by a piece of equipment 
similar to a huge dust pan, which would pick 
up the loose coal. After the coal was scooped 
up, roofers would drill holes in the rock above 
and insert an iron rod to hold up the roof. 
Then the whole sequence would resume — 
dirty and rugged work, but not too dangerous 
in a well run mine. 

The Ties that Bind 



On my house calls, I repeatedly witnessed the 
strength of family ties in this part of Kentucky. 
The county had no nursing home, and the sick 
and the physically and mentally disabled were 
often ensconced in the cluttered central room 
that their families used as a living room, dining 
room, and kitchen. 

I learned a great deal about my patients 
when I made those house calls — much more 
than during an office visit. A careful observer 
can walk into a home, whether in Kentucky or 
Haiti, and in just a few moments learn a great 
deal about the patient, the status of his dis- 
ease, and the quality of his household relation- 
ships. I remember one couple, for example, 
who were in their sixties and suffered from 
hypertension. I would call on them to monitor 
their blood pressure. Invariably, I would go 
into their kitchen to check what was simmer- 
ing on their stove. Often it was shucky beans 
with a large chunk of salt pork floating on top. 



"This is part of your problem," I would say, 
poking at the pork. 

I learned too what 75 years of dedication by 
the nurse midwivcs had meant to the people of 
eastern Kentucky. One day, I fielded a call over 
the short wave radio from a nurse-midwife who 
announced, "I'm bringing in a patient with a 
ruptured ectopic pregnancy!" The nurse soon 
appeared in her Land Rover, her patient attached 
to an intravenous line and securely bedded on 
the floor of the vehicle. The woman's husband 
was offering her comfort. My interview and 
exam turned out to be superfluous, because the 
nurse had coolly brought the situation under 
control. When I operated, I evacuated consider 
able blood from the patient's abdomen, clamped 
and removed the bleeding fallopian tube, closed 
the abdomen, and reported to the husband. He 
listened politely but directed most of his ques 
tions to the nurse, as was proper. She was the 
person he knew, and the one who had intervened 
immediately to save his wife's life. To him, I was 
just another pair of hands. ■ 

Frank]. Lepreau,]r. '38 is medical director of the Rose 
Hawthorne Lathrop Home, a facility for terminally ill 
cancer patients in Fall River, Massachusetts. 



OLD KENTUCKY HOME: 
A typical dirt road in 
Hyden, Kentucky in 
1931. The roads were 
often muddy and 
sometimes completely 
flooded. 




SPRING 2000 • HARVARD MEDICAL ALUMNI BULLETIN 




by Christina Anderson 




ROM HIS FIRST ROTATION AS A YOUNG 

doctor in a newborn intensive care unit, Nicholas Guerina 
'83 knew he wanted to specialize in saving babies. Now he 
is on a mission to lend a hand to infants who need it 
most — those in poor and war- torn countries. 

Guerina spent two months in Albania last spring, tak- 
ing care of refugees who fled Serb persecution during the 
conflict in Kosovo and assessing health care needs in the 
region. His journey began in Kukes, a town bordered by 
abandoned factories and potato fields at the foot of a small 
mountain in northeastern Albania. During the conflict, 
Kukes, ordinarily home to 20,000 people, played host to 
more than 300,000 Kosovo Albanian refugees. Half of 
them lived in camps run by various international agencies; 
the rest were taken in by local families. 

The people who lived in the camps, Guerina says, 
responded to the austere conditions with ingenuity, 
designing makeshift furniture to make their tents as 
homey as possible. Although shelling from the Kosovo 
border served as an audible reminder of the conflict raging 
around them, life in Kukes was relatively peaceful. 'The 
Kosovo Albanians showed remarkable grace," Guerina 
says. "I never saw them arguing or outwardly displaying 
the effects of the tremendous strain." 

Livestock and trucks were kept on the outskirts of the 
camps, and supplies were flown by helicopter to Kukes up 
to 15 times a day. Each camp had a medical facility, with a 
doctor-to-patient ratio of one to 500. Guerina, director of 
perinatal infectious diseases at New England Medical 
Center's Floating Hospital for Children, shared an apart- 
ment in Kukes with three other doctors. The physicians 
had all come to Albania under the auspices of Child Advo 
cacy International, a British aid organization. 

After a morning security meeting, the doctors would 
make their rounds of the camps and Kukes Hospital. One of 



The challenge of ensuring a healthy 
beginning for babies is heightened 
in the resource-deprived Balkans 



54 HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 





FAMILY MATTERS: A man and 
his grandson hold hands in 
front of their tent at "Kukes 
One," one of seven camps 
set up for Kosovo-Albanian 
refugees outside Kukes, 
Albania. The man's wife sits 
in the opening of their tent. 



SPRING 2000 • HARVARD MEDICAL ALUMNI BULLETIN 55 




he war was over, and they wanted to go home. 
Within five days Kukes became a ghost town." 






their most significant contributions, 
Gucrina says, was setting up a program 
that encouraged women to breastfeed. 
Many women had stopped lactating on 
their journey to the camps and did not 
know that they could resume. "We were 
very worried about dysentery spread- 
ing," Guerina says, "and the best way to 
prevent that was with breastfeeding." 

Guerina arrived in Kukes with crates 
of donated supplies, including intra 
venous catheters and feeding tubes, 
which he and his colleagues used to 
teach the medical staff in Kukes how to 
feed premature babies. The internation- 
al doctors showed the Albanian hospi- 
tal staff how to concoct fortified nour- 
ishment for babies. "It became clear that 
very simple interventions could spell a 
dramatic difference for babies who 
would otherwise die," Guerina says. 

Six weeks after the medical team 
arrived, the conflict in Kosovo ended 
and a peace treaty was signed. Guerina 
recalls with emotion the arrival of 
NATO troops in Kukes. "Suddenly the 
town, which already was busy, was 
inundated with refugees who emerged 
from houses and tents cheering." By the 
time the troops were ready to oversee a 
coordinated reintegration, the refugees 
had left for the border, piling their 
belongings onto donkeys and carts. 
"Nothing could stop them," Guerina 
says. "The war was over, and they want 
ed to go home. Within five days Kukes 
became a ghost town." 

Guerina also headed for the border 
with a group of doctors to assess the 
medical facilities in Kosovo. There, they 
encountered dedicated and talented 
professionals hampered by a shortage 
of basic, life-saving equipment — much 
of which had been stolen by departing 
Serbs. In some cases, Guerina says, the 
health care workers also lack informa 
tion. As a result, newborn mortality in 
full term babies is almost ten times 
higher in Albania and Kosovo than in 
Western Europe and the United States. 



Overcoming Ethnic Divisions 

Inadequate equipment and training are 
major problems in Kosovo, Guerina 
says, yet they pale in comparison to the 
more insidious obstacles: prejudice, 
fear, and hatred stemming from cen- 
turies of ethnic and religious disputes. 
"Another part of our goal is to reinte- 
grate the sides, but it's..." His words trail 
off as he shakes his head. "They find it 
very painful to forgive." 

This enmity places additional limita- 
tions on medical care. For instance, in 
the town of Mitro\ica, a hotbed of eth- 




INNOCENTS ABROAD: A baby sleeps in 
a bassinet in Kukes Hospital in Albania. 
Newborn mortality in full-term babies 
is almost ten times higher in Albania 
and Kosovo than in the United States. 



nic tension in northern Kosovo, the Ibar 
River divides the Serb and Kosovo- 
Albanian populations. Because the hos- 
pital lies on the Serb side, when Guerina 
and his group visited, they were forced 
to set up a tent to treat the ethnic Alba- 
nians. "The hospital normally had 3,600 
deliveries a year," he says, "yet they did 
not have a single patient there, because 
many of the Serbs had left, and none of 
the Albanians would see Serb doctors." 



The fear and resentment ran so deep 
that more than one set of parents said 
that they would let their children die 
before allowing them to be treated by 
Serb doctors in Belgrade. The father of a 
baby who needed a brain shunt to 
relieve hydrocephalus was adamant 
that the child not be taken to the capi- 
tal of Serbia. 

"I realized for the first time just 
how difficult the task in Kosovo was 
going to be," Guerina says. "The inten- 
sity of the animosity between many 
Kosovo Albanians and Serbs once the 
refugees returned to Kosovo caught 
me off guard." Two children died as 
relief workers tried to organize their 
transport to a hospital in Macedonia, a 
more neutral country. The Ministry of 
Health is now working to staff the 
medical facilities with members of 
both ethnic groups. 

On the Home Front 



In the quiet, dimly lit newborn inten 
sive care unit at Newton-Wellesley 
Hospital, where he is on call, Guerina 
points to a radiant warmer, which con 
tains most of the basic life -support 
materials he hopes to bring to the 
Balkans. In contrast to the medical 
facilities he toured in Albania and 
Kosovo, in this hospital, storage space 
is harder to find than supplies. The 
walls are lined with well stocked bins 
containing everything from two -ounce 
bottles of formula to "small masks" and 
"teeny tiny masks." 

Guerina is called to the delivery room 
for a Caesarean section. When the team 
delivers a ten-pound boy, the baby gives 
out a yell, and a doctor hands him to 
Guerina and a nurse, who together per- 
form the "pulmonary toilette." They put 
the infant on the radiant warmer, where 
he is dried and prodded. Guerina suc- 
tions amniotic fluid from the boy's nose 
and mouth and gives him a rapid head 
to-toe examination. 



56 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING 2000 



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IN SAFE HANDS: In Boston, Guerina examines a premature infant with respiratory 
distress syndrome. In Albania and Kosovo, most infants with this condition die. 



The delivery team assesses the baby's 
heart rate and breathing. His oxygen 
level rises, and his skin flushes from 
blue to pink. "He is putting up with this 
sportingly," Guerina says as he inserts a 
finger in the newborns mouth to calm 
him. The nurse attaches a probe that 
reads the baby's temperature, prompt 
ing the warmer to apply just the right 
amount of heat. Another device on the 
warmer helps the health care workers 
assess the baby's Apgar score, which 
climbs to a healthy nine after five min- 
utes. The boy is swaddled and Guerina 
hands him to his father. 

In this case, the transition from 
womb to world was smooth. Babies 
delivered in Albania and Kosovo are not 
always so fortunate, Guerina says. In 
many of the hospitals he toured, when 
problems arise, nurses have to run the 
babies upstairs. The delay in the babies' 
treatment leads to a higher frequency of 
brain damage. 

"Although radiant warmers are 
ideal tools, you don't have to be high- 
tech to get better results," Guerina 
says. "Our goal isn't to try to provide 
the Balkan countries with the type of 
intensive care units we have in the 



United States, but to address the easi- 
ly corrected conditions. 

"We can all learn to use our 
resources better," he adds. "We go 
through intravenous catheter^ like 
they're water, whereas in Kukes, 
they're like gold." 

A Breath of Life 



When he first returned to Boston last 
summer, Guerina established the 
Balkan Pediatric Fund to help raise the 
level of neonatal care in that region. 
The wealth of technology and experi- 
ence that exists in the United States, 
he says, can be shared simply by pro- 
viding the money to translate a manu- 
al and train a few caregivers in key 
centers who, in turn, will train others. 
Guerina has already raised enough 
money to translate into Albanian the 
Neonatal Resuscitation Program, a manual 
developed by the American Heart 
Association and the American Acade- 
my of Pediatrics to address the most 
common complication that arises dur- 
ing delivery — depressed or absent 
breathing. In Albania and Kosovo, as 
many as two thirds of newborn deaths 



or injuries are oxygen-related; imple- 
mentation of the resuscitation pro- 
gram, Guerina predicts, will have a 
significant impact on infant mortality 
and morbidity. 

In addition, Guerina helped establish 
a perinatal-neonatology committee, 
which will appoint a group of doctors 
to begin training the delivery room 
staffs of 35 birthing centers throughout 
Albania and Kosovo. At least two physi 
cians will be identified in each region to 
provide ongoing training to as many as 
300 caregivers. This model of regional 
ization, widely used in the United 
States, is particularly suited to the 
expensive, cutting edge technology 
required in neonatology, Guerina says. 
His long term goal is to outfit each 
regional center with life support mate- 
rials such as oxygen, ventilators, laryn- 
goscopes, intubation materials, and 
radiant warmers — equipment needed 
to stabilize a baby before transfer to one 
of the major children's hospitals in the 
larger cities. 

For now, Guerina says, "we are hop- 
ing to help the full-term babies who 
don't require high tech interventions. 
Often all a baby needs coming out of a 
delivery with respiratory distress is a 
self- inflating bag." Even in remote vil- 
lages, where it would be too expensive 
to supply clinics with oxygen and med 
nation, the resuscitation program will 
help. The lessons show how to provide 
adequate warmth, give chest compres- 
sions, and use basic equipment such as 
breathing bags and masks. "It sounds so 
simple," Guerina says, "and, in fact, it 
really is, but if you don't memorize the 
steps, problems arise no matter how- 
experienced you are." 

Despite the tension in the region, 
Guerina says, both the Albanian manu 
al and a version that had already been 
translated into Serbo-Croation have 
been well received and may even do 
more than raise the standard of care. 
"Medicine is one of the areas in which 
you have the potential to foster under 
standing between different groups, 
because health is a common language," 
Guerina says. "Through that language, 
there's a real opportunity to cultivate 
peace as well." ■ 

Christina Anderson is a freelance writer based 
in Someryillc. Massachusetts. 



SPRING 2000 • HARVARD MEDICAL ALUMNI BULLETIN 



57 



CLASS NOTES 



NEWS ABOUT ALUMNI 



Prentiss L. Hyder 

1 933 received the annual Physician 
Leadership Award from the 
Christus Spohn Health Sys- 
tem in March 2000. Hyder 
was honored for the service 
he has provided to the Cor- 
pus Christi, Texas community 
since 1938. The award dinner 
was held at the Corpus 
Christi Country Club. 

Carter R. Rowe 

"I retired in 1991 from active 

practice at the Orthopedic 

Service at Massachusetts 

General Hospital and HMS. 

Mary and I continue in good 

shape." 

Carl E. Taylor 



1 94 1 "I have returned from a Nepal 
expedition during which we 
walked from the Indian bor- 
der to the Tibetan border. 
We repeated a health survey 
done 50 years ago — the first 
ever done in Nepal — in the 
same villages. We were 
remembered because we 
were the first expedition 
permitted into the interior 
two years before Nepal 
opened up to the outside 
world. The changes are 
amazing, especially in health, 
and not all good." 

Charles Q. C arothers 

1946 "My grandson, Joshua T 
Carothers, is in his second 
year of medical school at the 
University of Cincinnati. He 
will represent the fifth gener- 
ation of the Carothers family 
to graduate in medicine." 

H ow ard M . Spiro 

1 947 "I have joined the private sec- 
tor as a part time consultant 
in New Haven, now that I 
have retired from Yale after 
44 years." 



Mor ga n Vi g ner o n 

1 949 "I am still savoring our won- 
derful 50th reunion. Congrat- 
ulations to Tom Parker and 
Lee Walton for their inspir- 
ing fundraising from our 
famous class. On to the 55th!" 

Harvey Rothberg 

1953 "I'm as busy as ever in inter- 
nal medicine-oncology prac- 
tice in Princeton, New Jersey, 
but I am looking forward to 
retirement in June 2000." 

Be rna r d Kliman 



1955 "My full retirement begins 

with the new century. I hope 
to travel more with Phyllis 
and to visit with the grand- 
children, Marissa and Aman- 
da. It was a chore to have pro- 
static cancer, now cured by 
surgery. That experience con- 
vinced me to retire for the 
second time from active 
endocrinology and to follow 
medical advances as an 
observer. I'm looking forward 
to our 45th reunion." 

John J. Ross 



1956 "I was just notified by 

the dean that I have been 




appointed professor emeritus 
in the Department of Pedi- 
atrics at the L'niversity of 
Florida College of Medicine 
after serving the institution 
for 34 years as chief of pedi- 
atric neurology and program 
director." 

Sanford I. Roth 

"I have finally pulled the trig- 
ger and retired as a professor 
and assistant dean for admis- 
sions at Northwestern Uni- 
versity Medical School. We 
are moving to Chatham, 
Massachusetts to our new 
house, which we spent the 
last one and a half years 
building. We will be glad to 
see classmates." 

George J. Hill II 

1957 "In May 1999 I received my 
master's degree from Rut- 
gers University in the field of 
the history of science, medi- 
cine, and technology. I am 
now continuing my study of 
history as a full-time gradu- 
ate student for a PhD at 
Drew University in Madison, 
New Jersey." 

John A. Retzlaff 

"We are enjoying our new 
home in Medford, Oregon. 
We have plenty of room for 
guests — come visit us!" 

Sheila B, Blume 



1958 "I am happily semi -retired, 

working on legal cases, teach- 
ing, and consulting. I am also 
painting quite a lot." 



Robert S. Rosson 

"As of January 2000, 1 
decreased my gastroenterolo- 
gy practice to three days a 
week. I've been looking for 
ward to more time with 
Eileen and the family and 



58 



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